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Visual perception in children 6 to 8 years old with a diagnosis of spina bifida including a group who have hydrocephalus as well
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Visual perception in children 6 to 8 years old with a diagnosis of spina bifida including a group who have hydrocephalus as well
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Content
VISUAL PERCEPTION IN CHILDREN 6 TO 8 YEARS OLD
WITH A DIAGNOSIS OF SPINA BIFIDA INCLUDING
A GROUP WHO HAVE HYDROCEPHALUS AS WELL
by
Janet Supowitz
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)
May 1985
UMI Number: EP62556
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
Oissôrtalton MwWisNng
UMI EP62556
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
Microform Edition © ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code
ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106- 1346
UNIVERSITY OF SOUTHERN CALIFORNIA
TH E G RA D UA TE SCHO O L
U N IV E R S IT Y PARK
LOS A N G E LE S. C A LI F O R N IA 9 0 0 0 7
O.Th.
S’ )S?
This thesisf w ritten by
.J[ajiet..j£LuçLQwi.tz..........................
under the direction of h.^ic...Thesis Comm ittee,
and approved by a ll its members, has been p reÂ
sented to and accepted by the D ean of The
Graduate School, in p a rtia l fu lfillm e n t of the
requirements fo r the degree of
Master of Arts
< s d / i
- - - - - -
Dean
D a te....
THESIS COMMITTEE
Chairman
ACKNOWLEDGMENTS
Many people contributed much in time and expertise to
this Master's thesis. I would like to thank our educaÂ
tional director and guide through research methods,
Elizabeth J. Yerxa, Ed.D., as well as my committee memÂ
bers, Florence Clark, Ph.D., and Sandra Burnett, M.A.,
for their contributions to this project. Special thanks
is extended to my chairperson, Ruth Zemke, Ph.D., for the
extensive time and support she has given to me during
this long process. Her knowledge, insights, and
experience have been invaluable.
I would also like to thank the Spina Bifida Clinic
staff of Orthopedic Hospital of Los Angeles with special
thanks to Wendy Feldman, MSW, for the time and energy she
spent in helping me, and to Dr. Andrew Sew-Hoy for
providing me with extra learning opportunities.
Thanks also go to many of my peers for their underÂ
standing support, their encouragement throughouot, and
their shoulders to lean on as they were going through the
same process: Mary Joyce Pratt, Susan E. Wiley, and
Janet H. Muniz.
The contribution of Marian Karsjens and her family
has been much more than that of editors, word processors,
___________ ii
and proofreaders as I surely have stretched their
patience to the limit more than once in meeting
deadlines.
Finally, I would like to thank my family who have
been constant in their love and support of me. I would
like to thank those who dragged me to their offices on
quiet weekends (Paul A. Love and Jerry Katz) as well as
those who provided a much needed escape after deadlines
were met (the Fields family). Most of all, I would to
thank my parents for their continuouos care and their
wise guidance.
I would also like to acknowledge two people whose
influence in my life has been great, although they did
not live to help me celebrate the accomplishments: my
grandmother, Goldie Darling Love, and my uncle, Murray S.
Love.
To all of you and others as well, I say: thank you
very much.
Ill-
TABLE OF CONTENTS
Chapter
I. INTRODUCTION TO THE PROBLEM............... 1
Statement of the Problem ................... 3
Purpose of the Study....................... 4
Research Hypotheses ....................... 4
Other Questions to be Addressed........... 5
Rationale .................................. 5
Importance of the S t u d y ................... 7
Definition of T e r m s ....................... 10
Assumptions................................ 13
Delimitations .................... ..... 13
Limitations................................ 14
Summary and Overview....................... 14
II. A REVIEW OF THE LITERATURE................. 16
Spina Bifida................................ 16
Incidence and Regional Variations
of Spina Bifida......................... 18
Spina Bifida, Hydrocephalus, and the
Flow of Cerebrospinal F l u i d ............. 20
Pathology of Progressive Hydrocephalus . . . 23
Medical Management of Hydrocephalus;
The Shunting Process ..................... 24
Findings on Intelligence in Children with
Spina Bifida and Hydrocephalus........... 27
Visual Perception in Children with
Spina Bifida and Hydrocephalus........... 32
Description of the Research Instrument:
The Motor-Free Visual Perception Test
by Colarusso and Hammill................. 36
Conclusion ................................ 42
III. METHODOLOGY........................... 44
Research Design ............................ 44
Selection of Subjects ..................... 46
Instrumentation ............................ 47
Field Procedures and Methods of Data
Collection and Recording.......... 48
iv
Chapter
Data Analysis . • . ............... 50
Methodological Assumptions ................. 51
Limitations................................ Si
IV. RESULTS............ 53
Results of the Research Hypothesis ........ 54
Research Questions .......................... 57
Results of Additional Analysis ............. 58
Conclusion.................................. 61
V. SUMMARY AND DISCUSSION..................... 63
Summary.................................... 63
Results and Discussion of Their
Significance in Relation to the Previous
Literature in this Field................. 72
Overall Implications Affecting the Spina
Bifida Client ............................ 84
Limitations of this S t u d y ............... . 85
Implications for Future Research ........... 85
Conclusion.................................. 87
REFERENCES....................... . ^ 88
APPENDIX
A. Demographic Information Sheet ............ 92
B. Orthopedic Hospital Letter of Approval . . . 94
C. Letter to Guardians of Potential Subjects . 96
D. Subjects* Bill of Rights
Form of Informed Consent................... 98
E. Motor-Free Visual Perception Test
Scoring Sheet .............................. 105
F. Raw Scores and Perceptual Quotients
of Each Subject............................ 107
LIST OF TABLES
Tables
1. Perceptual Quotients and Summary Statistics for
Three Diagnostic Spina Bifida Groups ......... 54
2. Z Test Analysis of Hypotheses 1 and 2 ......... 56
3. t Test Analysis of Hypothesis 3 ................ 56
_ v . i .
LIST OF FIGURES
Figure
1. From MVPT Manual, Colarusso & Hammill, 1972 . • 39
2. Subject perceptual quotients plotted against
MVPT normal c u r v e ............................ 59
3. Expected percentage delimitations of the
normal curve .................................. 59
4. Histogram comparison of expected perceptual
quotients versus percentage obtained from
the sample.................................... 60
JVJLlJ
Chapter I
INTRODUCTION TO THE PROBLEM
A group of occupational therapists at the RehabiliÂ
tation Institute of Pittsburgh were discussing the cliniÂ
cal observation process when a particularly interesting
observation was mentioned. |It concerned the nature of
cognitive difficulty experienced by many children who
have spina bifida.| The therapists recalled that, along
with their more obvious physical problems, some of these
children displayed difficulty with language while others
displayed signs of perceptual deficits. It seemed to the
clinicians as though children who were shunted on the
right exhibited perceptual difficulties while children
who had been shunted (a procedure done to drain fluid and
thus control hydrocephalus) on their left sides were the
ones who showed language deficits.J These therapists
wondered whether the hydrocephalus itself or some quality
of the shunting procedure might be affecting the
children's performance in these areas.
This study, although originating from these clinical
questions, has metamorphosized a great deal since those
observations were made. The effect of shunting is itself
1
a very complex topic. The many variables that might
affect a child with a shunt include the number of operaÂ
tions to correct or replace the shunt in any given child,
different shunt models that require slightly different
variations on the operation, and even the possibility
that, while currently shunted on one side of the cranium,
the other side may have previously provided the channel
by which cranial pressure was decreased. These difficulÂ
ties in the shunting process tend to involve too many
variables in studying its association with language or
perceptual difficulties, especially as a research project
by a Master's student. Another difficulty in such a
study is the possibility of a low number of subjects
shunted on the left side of the head since the procedure
is more often done on the right side.
Therefore, it is hoped that limiting this study to a
description of the perceptual abilities of children with
spina bifida and describing the shunting history for
those hydrocephalic children for whom such a treatment
was deemed necessary will provide an appropriate beginÂ
ning investigation of the topic. Although there are some
studies of perception in children with spina bifida, they
are few in number and deal with wide ranges of both age
and level of spinal lesion. These few studies also
neglect to mention the side of the head upon which each
child has been shunted, limiting their usefulness for
those to whom this question would be relevant (Brunt,
1980; Miller & Sethi, 1971; Sand, Taylor, Rawlings &
Chitnis, 1973; Tew & Laurence, 1975).
Statement of the Problem
Occupational therapists treat children with spina
bifida (Grimm, 1976; Sand, Taylor & Hill, 1974), some of
whom are also hydrocephalic, including those in the
hydrocephalic category who have the excess fluid shunted
away from their brains. Occupational therapists also
treat children with perceptual problems (Ayres, 1979;
Siev & Freishtat, 1982). Since it has been shown that
many children with spina bifida also exhibit perceptual
deficits (Brunt, 1980; Miller & Sethi, 1971; Sand et al.,
1973; Tew & Laurence, 1975), it should be helpful to
occupational therapists to have a more specific descripÂ
tion of the types of visual perceptual deficits associÂ
ated with children who have spina bifida. It is believed
that if occupational therapists better knew what to
expect in the area of perceptual abilities, they would be
better able to choose appropriate assessments and to plan
therapy for these patients. Thus, the problem area for
this study, succinctly phrased in question form, is; "Is
there an association between having spina bifida and
having visual perceptual deficits? Might knowledge about
3
the potential association help occupational therapists to
better plan treatment for such clients?"
Purpose of the Study
The purpose of this study was to describe the visual
perceptual abilities of children 5 to 8 years old who
have spina bifida lesion involvement in the lumbar area
of their spinal columns.
Research Hypotheses
1. Children with the neurological disorder of spina
bifida who have never been diagnosed as being hydroÂ
cephalic will have statistically significantly lower
scores of visual perception when scores when perceptual
quotients (PQs) of the Motor-Free Visual Perception Test
(MVPT) (Colarusso & Hammill, 1972) are compared to the
normative data.
2. Children with spina bifida who have been diagÂ
nosed as having hydrocephalus and treated with shunts
will also have statistically significantly lower scores
of visual perception when PQs of the MVPT are compared to
the normative data.
3. It is further hypothesized that the children
with spina bifida who have shunted hydrocephalus will
have statistically significantly lower PQs than the group
of children with spina bifida who do not have
hydrocephalus.
Other Questions to be Addressed
1. What is the proportion of children with
hydrocephalus in the sample obtained for this study whose
shunt is on the left side of the head to those whose
shunt is on the right side?
2, Is there a relationship between the side of the
head upon which a child is shunted and the occurrence of
decreased visual perceptual abilities?
Rationale
The rationale for these one-sided hypotheses was
based upon the few studies found in the literature. The
directionality expressed in the hypotheses was based on
the empirical evidence provided by the few studies that
were published prior to the implementation of this study.
Since these studies are summarized and discussed in the
review of the literature (Chapter II), a brief mention of
each one will suffice in this section.
Tew and Laurence (1975) found that children with
spina bifida tended to have significantly lower scores on
tests of perception, intelligence and academic achieveÂ
ment than is found in the normal population of their
peers. A study by Miller and Sethi (1971) suggested a
prevalence of severe deficits in the perception of visuo-
spatial relationships among children with hydrocephalus.
The findings of Sand, Taylor, Rawlings, and Chitnis
(1973) indicated a tendency for children with spina
bifida to have significantly lower than normal scores on
the Frostig Developmental Test of Visual Perception.
This particular study may have confounded the data they
obtained by subdividing the experimental group too many
times. Finally, Brunt (1980) made observations conÂ
cerning perceptual-motor performance in meningomyelocele
children.
These studies of children with spina bifida and some
with hydrocephalus as well point to an association, in
children, of spina bifida with perceptual deficits.
These studies have therefore influenced the one-sidedness
of the hypotheses stated in this study. Furthermore, no
research is ever perfect and these few studies are no
exception: in one, the sample size is especially small
(Miller & Sethi, 1971), in another there is a question of
confounding the data due to subdividing the sample group
too many times (Sand et al. 1973), and in a third the
qualifications of those administering and interpreting
the Southern California Sensory Integration Tests (SCSIT)
are questioned (Brunt, 1980). More research therefore
was needed to support the idea that perceptual deficits
are more prevalent in children with the neurological
birth defect of spina bifida than they are in the normal
population. Futhermore, information on the two addiÂ
tional research questions addressed in this study was not
found in the literature reviewed by this researcher nor
through a Med-line computer search. Answers to these
questions would provide a baseline contribution to this
lack of information on the side shunted in hydrocephalic
children and its relation to perception.
Z tests were chosen to analyze two of the three
hypotheses because a sample was being compared to normaÂ
tive data that were based upon the sampling of 881 subÂ
jects. This normative sample was regarded as sufficient
to be considered an accurate representation of the popuÂ
lation and to warrant the use of Z tests, utilizing the
sample means and standard deviations as population
parameters.
Importance of the Study
Adequate perceptual abilities which involve the recÂ
ognition and differentiation of environmental stimuli are
a prerequisite to the satisfactory performance of most of
the activities that people routinely perform throughout
their daily lives. All perception requires synthesis
with previous experience. It is also the source of all
reception, storage, and use of information, as well as
7
the source of all communication and interaction with the
outside world (Sidman, 1982). In humans, one source of
perception that is of primary importance is through the
visual sensory systems. Impaired perceptual abilities
impair a person's functioning in the world around him and
it is an occupational therapist's task to aid in the
restoration of a person's functional capacity to whatever
extent is possible for that individual.
One particular patient population with whom occupaÂ
tional therapists often work is the group of children who
were born with a neurological disorder called spina
bifida. These children as a group are suspect of having
certain types of perceptual deficits in addition to the
other more obvious aspects of their disability. Such
obstacles include orthopedic problems to varying degrees
depending upon the level of the lesion in the spinal cord
and affecting ambulation; bowel and bladder incontinence
with its psychosocial as well as physical and health
related dimensions; and finally, the cognitive impairÂ
ments of varying degrees in the more involved cases
(Hole, 1978; Roaf, 1977). Gross kyphosis is also
commonly associated with spina bifida (Roaf, 1977).
While it is important for occupational therapists to
be aware of and to treat all aspects of a patient's disaÂ
bility as it impairs his functional abilities, it is
8
impossible for one research study to address all of the
above mentioned areas of concern. It was therefore the
goal of this study to focus in on the prevalence of
perceptual deficits in a sample of children with a diag-
! nosis of spina bifida and to compare them to normative
data. If this particular patient population does tend to
have specific types of perceptual deficits, it would be
advantageous for practicing occupational therapists to be
aware of such tendencies in order to both detect and
treat them in this area as soon as possible.
It is the types of visual perceptual abilities in
children who have spina bifida that this study was
designed to explore. The particular importance of perÂ
ceptual abilities is emphasized as the mastery of the
necessary skills in spatial relations becomes practically
implemented in the higher level cognitive aspects of
reading, writing, and arithmetic. Such skills are essenÂ
tial for success as a student and are assumed to be an
easily accessible part of an adult's repertoire. Since
occupational therapists participate in the restoration of
functional ability, information about a population's
tendencies toward perceptual impairment would assist in
the evaluation and treatment of the members of that
group.
Definition of Terms
Adaptive response: An appropriate action in which the
individual responds successfully to some environÂ
mental demand. It requires good sensory integration
while furthering the sensory integrative process
(Ayres, 1980).
Cerebrospinal fluid: A watery, clear, colorless fluid
that cushions the brain and spinal cord, protecting
them from shock. Usually shrinking or expanding of
the cranial contents is quickly balanced by an
increase or decrease of this fluid (Thomas, 1981).
Hydrocephalus: The increased accumulation of cerebroÂ
spinal fluid within the ventricles of the brain.
Results from interference with normal circulation and
with absorption of the fluid, and especially from
destruction of the foramina of Mazendie and Lushka.
Hydrocephalus may result from developmental anomÂ
alies, infection, injury, or brain tumor (Thomas,
1981). For the purposes of this study, a diagnosis
of hydrocephalus recorded in the patient's chart will
be used to indicate its presence.
Lumbar region of the spinal cord: The area of the spinal
cord encompassed by the five bones of the spinal
column that lie between the sacrum and the thoracic
vertebrae.
10
Meningomyelocele: Refers to a congenital defect in the
walls of the spinal cord in which the spinal cord
actually protrudes through the dorsal aspect, of the
vertebral column forming a fluid-filled (cerebroÂ
spinal fluid) sac of nerves and nerve roots. It is a
more specific term than spina bifida. In this study,
a diagnosis of meningomyelocele recorded in the
patient's chart will be used to indicate its
presence.
Perception: Awareness, recognition, and differentiation
of environmental stimuli by means of the senses.
Perceptual motor response: The motor output that is the
result of accurate sensory (or perceptual)
information or input.
Perceptual quotient: A deviation quotient derived from
means and standard deviations of the raw scores on
the MVPT associated with each 6-month age interval.
In this standard score, the mean for the quotients is
100 and the standard deviation is 15 (Colarusso &
Hammill, 1972).
Polygenic: Produced or caused by several genes (Thomas,
1981) .
Sensory integration: The organization and interpretation
of two or more stimuli for an adaptive response
11
(Ayres, 1980). This is operationally defined by a
child's score on the SCSIT.
Shunting: The treatment for cases of progressive hydroÂ
cephalus. It is a surgical procedure which utilizes
a shunt (piece of tubing) through which the cerebroÂ
spinal fluid flows. The shunt connects the ventricÂ
ular system of the cranial cavity with a suitable
cavity such as the atrium of the heart or the periÂ
toneal cavity (Thomas, 1981). For the purposes of
this study, charted documentation will be used to
indicate its presence.
Spina bifida: A congenital defect in the walls of the
spinal canal caused by a lack of union between the
laminae of the vertebrae. As a result, the membranes
of the cord may be pushed through the opening. The
lumbar portion of the spine is the area most commonly
affected (Thomas, 1981). Meningomyelocele is a more
specific term referring to cases in which there is an
actual protrusion of the spinal cord through the
dorsal aspects of the vertebral column (Brunt, 1980) .
For the purposes of this study, a diagnosis docuÂ
mented in the patient's chart will be used to
indicate its presence.
Visual perception: The meaning the brain gives to senÂ
sory input from the sense of sight (Ayres, 1979).
12
will be operationally defined for the purposes of
this study as the score received from the MVPT
(Colarusso & Hammill, 1972).
Assumptions
1. Visual perception can be measured by the Motor-
Free Visual Perception Test.
2. The Frostig Developmental Test of Visual
Perception is a valid measure of visual perception.
Delimitations
The scope of this study has been delimited by sample
size, geography, the ages of the children, and their
level of neurological lesion in the spinal cord. This
study has concerned itself with only:
1. Children in the Southern California geographic
area who receive treatment at Orthopedic Hospital of Los
Angeles.
2. Children of ages 5 to 8 years.
3. Children whose level of spinal lesion is in the
lumbar region of their spinal cords since most spina
bifida lesions are in this area. This, however, will not
allow for comparisons of perceptual abilities with chilÂ
dren whose spina bifida lesions are in other areas of the
spinal column.
13
4. A sample of convenience rather than a truly
random sample.
Limitations
Requiring the voluntary consent of a subject means
that the qualities of a volunteer may in some way be
different from those who decline to participate in this
study. This could possibly affect the generalizability
of the study to those who are likely to render consent.
None of the spina bifida subjects or their parents
declined to participate in this study when they were
approached in clinic at Orthopedic Hospital of Los
Angeles.
Summary and Overview
This chapter provided an introduction to the problem
area of the nature of visual perceptual abilities of
spina bifida children. The specific purpose of the study
was also presented along with hypotheses and additional
questions. The rationale and importance of the study
were discussed. Terms were defined; assumptions and
scope of the study were delineated. Chapter II will
provide an in depth review of the pertinent literature
and Chapter III will outline the methods and procedures
that were used in this study. Chapter IV will state the
results of the analyzed data and Chapter V will conclude
14
this thesis with a summary of all the previous chapters,
a discussion of the results in light of the previous
literature and finally make recommendations for future
research in this topic area.
15
Chapter II
A REVIEW OP THE LITERATURE
In order to proceed with this study, it is necessary
to have an understanding of the birth defect, spina
bifida, as well as hydrocephalus, and the nature of the
flow of cerebrospinal fluid through the ventricles in the
brain and the spinal column. The nature of the shunting
procedure should also be appreciated. This chapter will
present such material to the reader as well as review
information on the perceptual performances of children
with hydrocephalus and spina bifida. Finally, the
instrument intended for use in this study, the Motor-Free
Visual Perception Test (MVPT), will also be discussed.
Spina Bifida
The human spine consists of a sequential series of
bony vertebrae that protect the sensitive and neurologi-
cally complex cord within. Spina bifida, in its most
literal sense, refers to the developmental separation of
the vertebral elements in the midline (Brocklehurst,
1976). This vertebral separation, however, is a feature
common to a large range of conditions, most of which
16
involve the dorsal elements of the vertebrae. Thus, when
the vertebral body is found to be cleft, it is specified
as spina ventralis bifida. Bigge and Servis (1978) desÂ
cribed spina bifida as occurring when "a portion of the
spinal cOrd is not enclosed by the vertebral neural
arches, and a distortion of the spinal cord and nerve
roots result in a neurological disorder and related
deformities" (p. 358). They also mentioned that varying
degrees of distortion of the spinal cord affect the
resulting neurological deficit. Hole (1978) states that
spina bifida results if the laminae of the vertebrae fail
to unite during embryological development; this, too, is
a very general definition.
In more specific terms, there is spina bifida aperta
which refers to spina bifida lesions over which the skin
is either completely deficient (exposing the neural tisÂ
sue and open spinal canal) or is incompletely epithe-
lialized. This indicates that the lesion is potentially
open to infection and is an important distinction in
clinical management (Brocklehurst, 1976). A similar
condition, meningomyelocele, refers to cases in which the
spinal cord protrudes through the dorsum of the vertebral
column forming a fluid-filled sac of nerves and nerve
roots. Another specific type of lesion is spina bifida
oculta, where the epithelialized skin covers the spina
17
bifida lesion; it is compatible with long postnatal
survival without treatment (Brocklehurst, 1976).
Due to the distortion of the spinal cord, neurologiÂ
cal transmission of both sensory and motor responses is
disrupted. Thus, related problems that occur in spina
bifida patients may include paresthesias, paralysis, uriÂ
nary tract disorders and infections, orthopedic deforÂ
mities, brittle bones in the lower extremities, problems
related to a lack of skin sensitivity and involving skin
breakdown, and abnormal blockage of the flow of cerebroÂ
spinal fluid in the cranial cavity (hydrocephalus) which,
if not corrected by surgical implementation of a shunt,
can cause severe mental retardation. Furthermore, hydroÂ
cephalus, even when shunted, may be accompanied by
learning problems of which therapists and special
education teachers should be aware (Bigge & Servis,
1978) .
Incidence and Regional Variations
of Spina Bifida
Many factors have been suggested as causes of spina
bifida: genetic, geographic, ethnic, and the season of
one's birth. According to the many epidemiological
studies collected by Brocklehurst (1976), the incidence
of spina bifida varies considerably in different parts of
the world. Despite the fact that spina bifida is the
18
most common crippler of newborns in the United States
(Seligmann, 1982), American studies show an incidence in
general lower than in Europe, with important ethnogeo-
graphic variations: in both Canada and the United
States, the mortality attributed to spina bifida was two
to three times greater on the Atlantic coast than on the
Pacific coast.
Brocklehurst (1976) reported two different studies
that link the incidence of spina bifida to the month in
which the infants were born. Guthelch's 1962 findings in
both Scotland and Manchester showed that the number born
per month between December and May was, on the average,
higher than those born between June and November.
Carter's 1974 study pointed out that the situation is
reversed in the southern hemisphere. Azen (1982), howÂ
ever , questions the appropriateness of the statistical
analyses these researchers chose to perform in these
studies.
The effect of migration upon ethnic differences has
also pointed to the involvement of environmental factors
in the occurrence of spina bifida. Brocklehurst (1976)
concluded, after reporting upon the genetic studies of
spina bifida, that the genetic pattern is one of a polyÂ
genic inherited predisposition. Considered with the
other epidemiological features of spina bifida, the
19
evidence points to a multifactorial etiology for spina
bifida (Brocklehurst, 1976).
Spina Bifida, Hydrocephalus, and the
Flow of Cerebrospinal Fluid
Brocklehurst (1976) credits Morgagni in 1761 as being
the first to clearly link hydrocephalus with the fluid
filled spina bifida tumor ; Morgagni also noted that
either condition might occur singly. Hydrocephalus, as
defined in Taber's Cyclopedic Medical Dictionary, results
from the increased accumulation of cerebrospinal fluid
within the ventricles of the brain as a result of interÂ
ference with normal circulation and absorption of the
fluid (Thomas, 1981). Increasing pressure in the ventriÂ
cles may cause an enlargement of the cranium in infants
whose cranial sutures have not yet united. As the venÂ
tricles become dilated and the brain tissue is forced
outward, the blood supply to these tissues is likely to
be reduced and the tissues may degenerate (Hole, 1978).
Cerebrospinal fluid then is defined as a watery, clear,
colorless fluid that cushions the brain and spinal
column, protecting them from shock. Usually shrinking or
expanding of the cranial contents is quickly balanced by
a homeostatic increase or decrease of this fluid (Thomas,
1981). Most of the articles and studies on hydrocephalus
concern the flow of cerebrospinal fluid through the
20
ventricles of the brain and the spinal column
(Brocklehurst, 1976; Brunt, 1980; Lorber, 1961; Tew &
Lawrence, 1973 & 1975); it is, therefore, important to
understand this process.
The ventricles of the brain are continuous with the
central canal of the spinal column and, like it, are
filled with cerebrospinal fluid. The lateral ventricles
are the largest, extending into the cerebral hemispheres
and occupying portions of the frontal, temporal, and
occipital lobes. A narrow space in the midline of the
brain beneath the corpus callosum comprises the third
ventricle. It is connected with the lateral ventricles
through openings in its anterior end, called the interÂ
ventricular foramina. The fourth ventricle is located in
the brain stem, just in front of the cerebellum, and is
connected to the third ventricle by a narrow canal called
the cerebral aqueduct or the aqueduct of Sylvius; it
passes lengthwise through the brain stem, connecting the
fourth ventricle with the central canal of the spinal
column with openings in its wall that lead into the
subarachnoid space of the meninges (Hole, 1978).
Projecting outward from the inner walls of the venÂ
tricles are tiny moss-like masses of specialized capilÂ
laries that secrete the cerebrospinal fluid. These are
the chorid plexuses which are present in the medial walls
21
of the lateral ventricles and the roofs of the third and
fourth ventricles, though most of the cerebrospinal fluid
seems to arise in the lateral ventricles. It then circuÂ
lates slowly into the third and fourth ventricles and
into the central canal of the spinal column as well as
into the subarachnoid space of the meninges by passing
through the wall of the fourth ventricle near the cereÂ
bellum. The circuit is completed by the cerebrospinal
fluid being reabsorbed into the blood gradually through
tiny cauliflower-like structures called arachnoid granuÂ
lations that project from the subarachnoid space into the
blood filled durai sinuses. Because, under normal cirÂ
cumstances, the cerebrospinal fluid is secreted and reabÂ
sorbed continually, the fluid pressure in the ventricles
remains relatively constant (Hole, 1978). Adjustments
are normally made to the slight shrinking or expanding of
the cranial contents by quickly balancing such changes
with an increase or decrease of this fluid (Thomas,
1981).
When, in the 1920s, the pathology of flow of the
cerebrospinal fluid became understood, the well-
established association between spina bifida and hydro-
}
cephalus underwent reappraisal: the concept that the
excess of fluid within the neuroaxis in some way caused
the spina bifida malformation was reversed so that it
22
became a matter of explaining how the malformation
obstructed the cerebrospinal pathway and caused hydroÂ
cephalus (Brocklehurst, 1976). Even more recently, Lewin
(1980) reported on findings from cat studies that seem to
indicate that hydrocephalus impinges more frequently upon
the brain's white matter (neural conductors), generally
sparing the grey matter, or actual nerve cells of the
brain. But whatever the impairments caused by the hydroÂ
cephalus may be and whether or not hydrocephalus occurs
as a secondary complication to spina bifida or whether
they are two separate components that develop from a
common teratogenic disturbance but independently of one
another as reported by Warkany and O'Toole (1981), their
association is a strong one; over 90 percent of all
patients with spina bifida develop some degree of hydroÂ
cephalus, and in children with congenital hydrocephalus,
over 80 percent have spina bifida (Lorber & Bassi, 1965).
Pathology of Progressive Hydrocephalus
The hydrocephalic process begins toward the end of
intrauterine development; dilatation of the ventricles is
present in nearly all cases of newborns having spina
bifida aperta although the skull circumference may not be
abnormally increased (Lorber, 1961). Thinning of the
cortex tends to accompany dilatation of the lateral venÂ
tricles and is more pronounced at the vertex and at the
23
occipital and frontal poles (Emery & Svitok, 1968).
There is also dilation of the third ventricle, consiÂ
derable thinning of the corpus callosum, and dilatation
of the supraspinal recess. Stretching then results in
the components of the limbic lobe (around the corpus
callosum) and also in the long fronto-parietal associÂ
ation fibers in the centrum semi-ovale of the hemiÂ
spheres. According to Brocklehurst (1976), the enlargeÂ
ment of the cranial vault follows the ventricular dilataÂ
tion and raises intracranial pressure. It is accompanied
by enlargement of the fontanelles and stretching of the
thin membranes which constitute the cranial sutures.
Distension and protrusion of the frontal bones results in
some flattening of the orbital roof. With the passage of
time, (from several months to several years), however,
the hydrocephalic process tends to undergo spontaneous
arrest (Brocklehurst, 1976).
Medical Management of Hydrocephalus:
The Shunting Process
Ninety percent of infants with spina bifida aperta
lesions have some degree of brain stem malformation.
Brocklehurst (1976) judged that 10 to 15 percent will not
require surgical treatment as the condition does not proÂ
gress to a level of clinical significance and he claimed
24
that there is no mental impairment in these patients in
later life.
At the present time, the treatment of hydrocephalus
with drugs is extremely limited due to their severe side
effects which require careful monitoring if used at all.
Thus, Brocklehurst (1976) stated.
Whenever hydrocephalus is clinically progresÂ
sive (as judged by abnormally increased skull
circumference, persistently increased anteÂ
rior fontanelle tension, episodes of respiraÂ
tory slowing, apnea, or decerebration, or a
persistent cerebrospinal fluid fistula from a
lumbar wound) then surgical treatment should
be undertaken without delay. (p. 72)
The operation of choice in straightforward cases is a
shunting procedure employed to drain the fluid away from
the ventricular system to the atrium or peritoneal cavity
(Brocklehurst, 1976; Hole, 1978).
Of interest here is not the procedure as a whole, but
the procedure as it affects the cranium. Shunting of the
ventricular part of the catheter is usually done through
a small temporal burr-hole beneath a small scalp flap on
the right side of the head. Because the superior vena
cava (here the blood flow is toward the heart) is used in
shunting cerebrospinal fluid to the atrium, the right
temporal area is preferred. Brocklehurst (1976) summed
up the technical perspective:
25
It is customarily assumed that the right side
of the head and neck is the best for the
initial shunting procedure because, compared
with the left side, the course of the
internal jugular vein down to the innominate
vein and superior vena cava is a fairly
straight line. (p. 74)
The right side seems to be preferred for peritoneal shunÂ
ting as well. Since the right hemisphere is believed to
be neurologically the dominant means of governing spatial
relations and other visual-motor perceptual provinces
(Eccles, 1977; Siev & Freishtat, 1982), do perceptual
deficits then tend to show up more frequently in these
children who have been shunted on the right side of their
heads than they do in the normal population of children?
What is the ratio of children shunted on the right side
to those shunted on the left and do those shunted on the
right have a greater amount of perceptual deficits than
those who have been shunted on the left?
Wealthall (1973) pointed out that, although the
treatment of hydrocephalus usually is based on the prinÂ
ciple of by-passing an obstruction, the mortality rate in
shunting approaches 3 percent per year. He also noted
that a great degree of variation in ventricular size is
produced by apparently similar degrees of obstruction and
that hydrocephalus may be provoked by the removal of the
spina bifida lesion-
26
In a study of the absorbing function of intracranial
pulsations, Wealthall seems to have found a second mechÂ
anism (besides the abnormally large cerebrospinal fluid
production which cannot be absorbed by transventricular
wall absorption) for regulating the size of sudden presÂ
sure changes in the cranio-spinal axis. This may be
compromised by abnormalities of the spinal theca or
cranio-spinal venous drainage. It seems that an increase
of intracranial blood during systole results in the pasÂ
sage of a quantity of cerebrospinal fluid out of the
fourth ventricle and into the basal cisterns. This mechÂ
anism appears to be important in the infant with spina
bifida, whereby removal of the spina bifida sac or
healing by fibrosis may remove part of the pulsation-
absorbing capacity, resulting in ventricular enlargement.
Wealthall*s (1973) conclusion suggested that the proviÂ
sion of pulsation-absorbing devices may allow equilibrium
of hydrocephalus to take place without the need for longÂ
term shunting procedures.
Findings on Intelligence in Children with
Spina Bifida and Hydrocephalus
In the 1890s, Chiari listed examples of four differÂ
ent types of cerebellar deformities that he believed
resulted from hydrocephalus. His type II deformity was
found in high concurrence with spina bifida.
__________ 27
Brocklehurst (1976) paraphrased Chiari's description as
an "inferior prolongation of the fourth ventricle into
the cervical spinal canal and with kinking of the interiÂ
orly displaced medulla oblongata" (p. 9). Brocklehurst
cautioned that it is yet to be determined whether this
brain deformity is due to hydrocephalus or is a primary
brain stem malformation etiologically independent of
hydrocephalus. With stresses like this one, or the
build-up of ventricular pressure on the cerebral cortex
in hydrocephalus, or the stresses of the shunting proceÂ
dure on the brain, it is not surprising to find intellecÂ
tual impairments in the spina bifida, hydrocephalic
group. Three studies that explore such a correlation are
discussed.
One aspect of a study by Tew and Laurence (1973) was
to examine the resemblances and differences in intelliÂ
gence test scores between patients with spina bifida,
their matched controls, and the siblings of both groups.
Fifty-nine children with spina bifida and their 44 sibÂ
lings, and 59 matched control children and their 63
siblings were examined in their homes on either the
Stanford-Binet Intelligence Scale for Children (2 to 7-
year-olds) or the Wechsler Intelligence Scale for
Children (8 to 15-year-olds). The siblings of both
groups were included to provide greater comparability for
28
variables such as inheritance, social class, and the
parents* educational levels and child-rearing practices.
The IQ scores of the spina bifida children were lower
and had a wider spread than their normal controls. There
was also a statistically significant difference of 26 IQ
points between the 59 spina bifida children and their 44
siblings (p < .001); there was no difference between the
scores of the 57 control cases and their 63 siblings.
The IQ scores of the siblings of the spina bifida chilÂ
dren, the control children, and their siblings were virÂ
tually identical. The examiners concluded that the lower
IQ scores of the spina bifida children did not reflect
social class membership, but rather maldevelopment of, or
damage to, the central nervous system. Because it is
generally expected that children within a family will be
in the same broad band of intelligence. Tew and Laurence
(1973) suggested the prudence of taking into account the
intelligence of siblings when assessing a child with
spina bifida.
Villani, Giani, Giovanelli, Tomei, Zananone, and
Motti (1976) examined skull changes and intellectual
status in hydrocephalic children following cerebrospinal
fluid shunting. They attempted to assess the incidence
of cranial changes and their possible correlation with
mental development in the course of a follow-up program.
______ 29
Shunt procedures were performed in 258 hydrocephalic
infants and children during the 14-year period from 1960
to 1973. The specific type of shuhting procedure used
for each child was noted and 76 patients were studied at
least once in the course of the follow-up program which
extended from 2 to 12 years after surgery. Evaluation
took the form of radiological examination of the shunt
system in conjunction with neurological examination and
assessments of intelligence (IQ) and social adjustment.
The incidence of skull changes in shunt-treated, nonÂ
tumor al, hydrocephalic children was found to be high. A
relationship between skull changes and low intracranial
pressure was noted, indicating to the investigators that
impairment of mental development parallels the degree of
skull changes. A close relationship between impaired
mental development and cerebrospinal fluid hypotension
was suggested. The researchers indicated the need for a
shunting system sensitive enough to drain excess cerebroÂ
spinal fluid selectively, doing so only when it is above
physiological pressure ranges and readjusting once the
acute stage is over. Despite inconsistency in the amount
of follow-up on each subject and the emphasis in
detailing the types of cranial changes over the types of
mental impairments, this study does lend some support to
30
the relationship between the influences of shunting and
intelligence.
Tew and Laurence (1975) studied the longitudinal
effects of hydrocephalus on intelligence, visual percepÂ
tion, and school attainment with a sample of 59 spina
bifida children. Thirty-one had ventriculo-atrial
shunts, another eight had naturally arrested hydroÂ
cephalus and had not been shunted; the remaining 20 cases
presented no clinical signs of hydrocephalus. Controls
were matched for sex, place in family, locality, and
father's social class. At age 5, all were assessed on a
detailed battery of tests, including the Wechsler Pre-
School Intelligence Scale and the Frostig Developmental
Test of Visual Perception (DTVP). When each child
reached age 7, the teacher administered a standardized
reading, spelling, and mathematics test. The mean IQ in
shunt-treated children was lower, though not at a statisÂ
tically significant level, than the mean IQ of the eight
children with arrested hydrocephalus and was signifiÂ
cantly lower than in the children with only spina bifida
(£ < .01). The IQs of the spina bifida group were
significantly lower than those in the control group
(£ < .001), confirming the evidence that spina bifida
generally is accompanied by intellectual deficit. The
scores on the perceptual and academic achievement tests
_______________ 31
followed this lower than normal pattern which appeared to
be typical and led the authors to state.
The close correspondence between results of
the various tests implicates a general factor
in retardation, since lower intelligence,
visuo-perceptuo-motor impairment and poor
school attainments generally are found in
association with one another. (p. 132)
Studies like these tend to implicate the complexity
of separating out specific malfunctioning mechanisms of
the brain for evaluation. Intelligence tests tend to
rely on the perceptual integrity of the subject, yet
damage to the brain may be responsible for both intelÂ
lectual and perceptual deficits that have mutual effects
upon one another.
Visual Perception in Children with
Spina Bifida and Hydrocephalus
Miller and Sethi (1971) studied 14 children with
hydrocephalus alone or in association with spina bifida.
They were matched by age with controls who were normal
school children. The Bender-Gestalt and the DTVP were
used to evaluate the children. No experimental subject
obtained an age-equivalent score within 18 months of his
chronological age on the Bender-Gestalt and a similar lag
in perceptual functioning occurred on the Frostig test.
The differences between chronological ages and age-
equivalent scores on both tests were statistically
significant (£ = .01).
____________________________________________________________________32
Two subsequent experiments in this series by Miller
and Sethi (1971) attempted to identify variables in the
tests which could have spuriously lowered performance.
Miller and Sethi found that when motor and verbal
labeling components were removed experimentally through
use of tasks requiring selection from among five unfamÂ
iliar visual stimuli, the hydrocephalic children conÂ
tinued to show significantly fewer correct choices than
did the controls. The second of these experiments simÂ
plified a figure-ground test by substituting a neutral
background for a conflicting one. The hydrocephalic
children had greater difficulty than the control children
in rejecting irrelevant stimuli. Despite the small samÂ
ple size, this study suggested that children with hydroÂ
cephalus had a severe deficit in perception of visuo-
spatial relationships even when possible complicating
elements such as verbal and fine motor components were
removed from the tests.
In another study. Sand, Taylor, Rawlings, and Chitnis
(1973) also chose to evaluate the performance of children
with spina bifida on the DTVP. The primary goal of this
study was to provide additional information on visual-
perceptual functioning in spina bifida children to the
limited amount already known. A secondary goal was to
I determine whether the Frostig test yielded meaningful,
33
orderly differences in performance within the spina
bifida sample.
Thirty-seven subjects were classified by age, sex,
level of spinal cord lesion, and by presence or absence
of hydrocephalus. The children with higher level spinal
cord lesions (Tj^-T^2) tended to have lower scores on the
Frostig tests. It should also be noted that all ten of
the children in this group also had hydrocephalus,
whereas eight of the 29 children in the group did
not have hydrocephalus. While significant deficits and
differences between groups were noted on the Frostig
scores for Eye-motor Coordination, Figure Ground, and
Spatial Relations, it seems that the experimenters, in
; trying to subdivide the limited number of subjects into
so many different comparison categories, may have overÂ
lapped some of these categories (such as the high lesion
group with the hydrocephalic group) so as to confound the
results in each of those categories.
Brunt (1980), a member of the Physical Education
Department at Louisiana State University, built on the
information provided by the two preceding studies (as
well as from several others) to make more specific inquiÂ
ries as to perceptual-motor performance as reflected in
upper limb movements of meningomyelocele children. Brunt
claims to have given 13 tests from the SCSIT (Ayres,
_____________: _____________________ : ________________________34.
1974) to 41 children with meningomyelocele, but this
interested reader counted only 11 tests, two of which
were used in two different categories. Brunt selected
the tests to yield information about these children in
three areas of perceptual motor ability: praxis, bilatÂ
eral integration and spatial relations. Having based his
selection upon Ayres' reported factor analysis studies.
Brunt cites three factors of movement ability to be
characteristic of this group: (a) constructional and
gestural apraxia; (b) lack of bilateral coordination; and
(c) ataxic-like movements upon upper extremity extension
in a fine motor skill. Brunty however, tended to conÂ
centrate on the motor output required by the subjects
during the tests, ignoring the importance of an intact
sensory system to perceive a stimulus correctly and the
equally important aspect of being able to process inforÂ
mation received successfully in order to perform the
motor components expected to be produced by an intact
system. Also, although Brunt obtained the services of a
registered occupational therapist for aid in scoring the
tests, it was not documented that she was certified as
skilled in the administration and interpretation of the
SCSIT. The qualifications of those administering,
scoring, and interpreting the SCSIT in this study,
therefore, are now being questioned.
: ________ 35.
Description of the Research Instrument:
The Motor-Free Visual Perception Test
by Colarusso and Hammlll
Colarusso and Hammill (197 2) devised the Motor-Free
Visual Perception Test (MVPT) to be a practical test of
visual perception which avoids motor involvement and for
use in screening, diagnostic, and research purposes. It
is designed to be a quick, highly reliable and valid
measure of overall visual perceptual processing ability
in children. Perceptual tests which require a child to
make complicated graphic responses (the drawing of cirÂ
cles, squares, straight lines, and other designs) conÂ
found their perceptual assessments with motor requireÂ
ments (Colarusso & Hammill, 1972). One such test is the
commonly used DTVP by Marianne Frostig (1964). While
motor skills and visual perceptual skills are often
closely associated, Colarusso and Hammill noted that they
can also be separate skills and cite as an example the
many children with cerebral palsy who perform poorly on
such tests yet show no functional evidence of visual
disorders. They went on to say that such tests of
"visual perception" actually assess visual motor integraÂ
tion and are therefore suspect as measures of visual
perception. Colarusso and Hammill (1972) further critiÂ
cized many of these tests as being impractical for
research and screening purposes because of costly
36
materials, poor reliability, lack of adequate standardÂ
ization, and an excessive amount of time required to
administer them.
After analyzing the skills comprised in the construct
of visual perception, Colarusso and Hammill (1972)
divided them into five areas. The area of spatial relaÂ
tionships involves the ability to orient one's body in
space and to perceive the positions of objects in relaÂ
tion to oneself and to other objects. An example of a
spatial relationship task would be the perception picÂ
tures, figures, or patterns which are disoriented in
relation to one another such aS reversals (Colarusso &
Hammill, 1972). Visual discrimination involves the abilÂ
ity to discriminate dominant features in different
objects, such as the ability to discriminate position,
shapes, forms, colors, and letter-like forms (Colarusso &
Hammill, 1972). Figure-Ground perception is a form of
visual discrimination that involves the ability to disÂ
tinguish an object from its background. Visual Closure,
also a form of visual discrimination, involves the abilÂ
ity to identify incomplete figures when only fragments
are presented. Visual Memory involves the ability to
recall dominant features of one stimulus item or to
remember the sequence of several items (Colarusso &
Hammill, 1972). According to Colarusso and Hammill
----------------------------------------------------------------------- 3%
(1972), "these five categories are the most prominent
theoretical constructs of visual perception reported in
the current literature, and appear in one form or another
in most tests of visual perception" (p.2). By subjecting
105 various items to tests of item validity and level of
difficulty, 36 were selected for inclusion in the final
form of the MVPT, Items were then grouped according to
five categories of constructs and were arranged in order
of difficulty from easy to hard, each section having its
own specific administration directions. A sample item
for each section was provided both to ensure that the
child understand the direction and for teaching purposes,
if necessary. These examples were selected from the
original 105 items for their relative easiness (Colarusso
& Hammill, 1972).
The MVPT was then standardized on an unselected samÂ
ple of 881 normal children aged 4 through 8 who resided
in 22 states. Children identified as mentally retarded,
sensorially handicapped, and so forth were excluded. The
data pool also included samples from all races, economic
levels, and residential areas (urban, suburban, rural)
(Colarusso & Hammill, 1972).
38.
Reliability of the Motor-Free
Visual Perception Test
Three reliability procedures were performed on the
MVPT: test-retest, split-half, and Ruder-Richardson.
Inter-scorer reliability was not investigated due to the
objective nature of the scoring procedures on the MVPT.
The reliability coefficients and the number of children
involved in each computation are presented in Figure 1.
All coefficients were found to be statistically signifiÂ
cant at the .01 level of confidence (Colarusso & Hammill,
1972).
Futhermore, while the MVPT compared favorably with
other tests of visual perception, the major concern for
Colarusso and Hammill was its comparison with other
motor-free tests. They cite comparisons with the Chicago
Test of Visual Discrimination, along with the motor-free
subtests of the Illinois Test of Psycholinguistic AbilÂ
ities, the Marianne Frostig DTVP, the Weschsler
Reliability Correlation Coefficients for the MVPT
Test-Retest S p lit'H a lf Kuder'Richardson
Age N r N r N r
4 20 0.77 53 0.81 53 0.71
5 25 0.79 155 0.84 155 0.82
6 37 0.83 332 0.83 332 0.81
7 45 0.81 229 0.81 229 0.78
8 35 0.82 112 0.83 112 0.82
4-8 162 0.81 881 0.88 881 0.86
Figure 1. From MVPT Manual, Colarusso & Hammill, 1972.
39
Intelligence Scale for Children, and the Metropolitan
Readiness Tests. Colarusso and Hammill (1972) found that
only the Matching Subtest of the Metropolitan tests conÂ
sistently demonstrates reliabilities above .80.
Colarusso and Hammill (1972) observe, however, that this
subtest measures only one, limited perceptual skill:
visual discrimination of nonsymbolic forms.
Validity of the Motor-Free
Visual Perception Test
To determine the validity of the MVPT, Colarusso and
Hammill (1972) sought to answer two questions. Does the
MVPT measure visual perception? And how well does it
measure visual perception? In answering these questions,
they discuss three types of validity: content validity,
j construct validity, and criterion-related validity.
I Colarusso and Hammill (1972) checked content validity
by examining the test content to determine whether all
aspects of visual perception were included in the MVPT.
To insure content validity, items were constructed
proportionately under five visual perceptual skill areas
which were delineated and discussed earlier.
Three types of construct validity were determined:
age differentiation, correlations with similar tests, and
internal consistency. As visual perceptual skills are
reported to be developmental, it was expected that test
________________ 40
scores would show a progressive increase with age. When
tested, this expectation held at the .01 level of
confidence (Colarusso & Hammill, 1972).
Construct validity was also demonstrated by correÂ
lating the MVPT and other tests. Moderately high correÂ
lations between the MVPT and visual-motor tests with
lower correlations between the MVPT and achievement and
intelligence tests would be supportive evidence that the
MVPT measures visual perception. Correlation coeffiÂ
cients of the MVPT with the other perceptual tests ranged
from .31 to .73 with a median of .49. All coefficients
were sufficiently large to be statistically significant
at the .01 level of confidence except copying, which was
significant at the .05 level (Colarusso & Hammill, 1972).
Colarusso and Hammill (1972) ensured the internal
consistency of the MVPT through item analysis; biserial
correlations between "pass-fail" on each item and the
total test score were computed. Only those items yieldÂ
ing significant item-test correlations were retained in
the final form of the MVPT.
Colarusso and Hammill (1972) cited evidence to supÂ
port the motor-free nature of the MVPT as provided by
Newcomer and Hammill, who administered the MVPT and the
Visual Motor Gestalt Test to 85 motor impaired children.
They concluded that performance on the motor-free test
_____ — ________ 4, 1.
was independent of the degree of motor involvement, while
performance on the Bender test reflected significantly
the degree of motor involvement.
Conclusion
Unfortunately, the above-mentioned articles on visual
perception in spina bifida children made no mention of
the side of the head upon which the hydrocephalic chilÂ
dren in the various studies were shunted. It has been
pointed out that the right side is the customary one for
shunting, but no information has yet been obtained by
this researcher as to when or why shunting is done on the
left side. Despite the limited quantity of literature
I
i thus far uncovered on the subject of visual-perceptual,
I
; perceptual-motor capacities in spina bifida and hydroce-
I
I phalic populations, what is available does tend to
I indicate the presence of such deficits for these groups.
I It also raises some questions in addition to those posed
I in Chapter I. Does the lower extremity paralysis in
I children with spina bifida restrict their early opportu-
' nities for motor and perceptual learning? Perhaps senÂ
sory integration theory would provide a context in which
to attempt to deal with such a question. Or is malformed
or damaged brain tissue an overriding factor in the
perceptual dysfunction of this group? Whatever the
cause, they are a population commonly seen and treated by
-------------------- 42-
occupational therapists. Further investigation into the
nature of the perceptual problems of children with spina
bifida, and especially those with hydrocephalus, may aid
in the clinical treatment of this aspect of their dis-
I ability. This particular study proposes to conduct such
an investigation by using the MVPT to examine the
perceptual status of such children.
43
Chapter III
METHODOLOGY
This is a comparative study of the nature of visual
perceptual abilities of a sample of children who have the
neurological birth defect of spina bifida relative to a
normative sample of 881 children. Some of these children
also have hydrocephalus and, of them, most have had
shunts surgically implanted to relieve the intracranial
pressure caused by the hydrocephalus.
Research Design
Demographic information was collected and used to
divide the subjects in this research project into three
groups according to these diagnostic catagories:
1. The presence of spina bifida but not of
hydrocephalus.
2. The presence of both spina bifida and hydroÂ
cephalus where the hydrocephalus was considered to be
self-arrested and the child therefore had not been
shunted.
44
3. And the presence of both spina bifida and hydroÂ
cephalus where a shunt had been implanted to control the
hydrocephalus.
The mean MVPT PQ scores and standard deviations of
these three groups were determined and compared to the
normative data collected by Colarusso and Hammill (1972) .
It was hypothesized that: There would be a statistically
significant difference in the mean MVPT PQs of each of
the three different diagnostic groups from the normative
data. ^ tests were used to test these hypotheses along
with a Bovaronni procedure to retain an overall 95%
confidence level. The null hypothesis that there was no
statistically significant difference among the mean PQ
scores of the four groups on the MVPT (a = .05) was
tested. When the difference was statistically signifiÂ
cant, the alpha level of .05 was divided by the number of
times those data sets were used in order to determine a
level of significance which would maintain an overall 95%
level of significance. Specifically, this meant that
because each data set was used twice, a level of a = ,025
was set for statistical significance.
In addition to administering the MVPT, demographic
information on each subject was gathered. Such informaÂ
tion as age, sex, spinal level of neurological involveÂ
ment, presence of hydrocephalus, presence of a shunt and
____________________________ 45-
the side of its location (right or left), and the releÂ
vant medical history of each subject was gathered. This
information was recorded and used in reference to the
research questions about the proportion of hydrocephalic
children shunted on the left side of the head to those
shunted on the right side and the relationship between
the side of the head upon which a child is shunted and
the prevalence of deficits in visual perceptual abiliÂ
ties. IQ was not part of the routine medical information
found in the charts kept by Orthopedic Hospital. It was
therefore not used as a covariant to visual perception as
was originally planned in this study.
Selection of Subjects
It was hoped that a sample of 20 to 30 subjects from
the Los Angeles County area would be found from the
population of children aged 5 to 8 years who had been
diagnosed as having spina bifida with the affected region
of lesion being in the lumbar area of the spinal cord
(L^-L^). Twenty-three such children were in fact found
through a sample of convenience. Not all were from the
Los Angeles County area, but all came to Orthopedic
Hospital of Los Angeles to receive medical care and
regular check-ups. By working closely with the social
worker for the spina bifida clinic at Orthopedic HospiÂ
tal, this researcher learned when potential subjects had
----------- 4A.
appointments for the spina bifida clinic. The potential
subjects and their guardians were then approached while
they were waiting to see their doctors. All potential
subjects approached who had had their legal guardians
with them consented to participate in this research by
signing the informed consent. Two potential subjects
were accompanied by adults other than their legal guardÂ
ians and were thus unable to be included as consent could
not be properly obtained.
Instrumentation
The Motor-Free Visual Perception Test by Colarusso
and Hammill (1972) was used to provide a measure of the
perceptual status of each subject. As was mentioned in
the literature review (Chapter 2), the MVPT was designed
to be a practical test of visual perception without
requiring motor output from the person being evaluated.
It can be administered quickly, and is a highly reliable
as well as a valid measure of a child's overall visual
perceptual processing ability. It is also one of the few
tools that was designed for research as well as screening
and diagnostic purposes.
The product of the MVPT is expressed as both a raw
score and as a perceptual quotient. The perceptual quoÂ
tient (PQ) is a deviation quotient derived from means and
standard deviations of raw scores associated with each 6-
__ 47
month age interval. In this standard distribution, the
mean for the quotients is 100 and the standard deviation
is 15. A sample size of 881 was used by Colarusso and
Hammill (1972) to obtain these normative data. The
validity and reliability for the MVPT are quite good and
have been discussed in Chapter 2. A one-page demographic
information sheet was developed to record relevant mediÂ
cal information and is displayed in Appendix A. It was
designed especially to aid in the collection of informaÂ
tion regarding the shunt location in the hydrocephalic
cases. This information was obtained from the subject's
medical chart.
Field Procedures and Methods of
Data Collection and Recording
Orthopedic Hospital of Los Angeles was contacted in
order to find appropriate subjects. Once the research
proposal passed that hospital's Rights of Human Subjects
Committee (see letter. Appendix B), the researcher was
instructed to contact the social worker for the Spina
Bifida clinic. By working in close association with her,
a plan was formulated to obtain subjects in a manner that
would cause the least amount of inconvenience to them:
they were to be tested while they waited to see the
doctor and medical team at the Spina Bifida Clinic of
Orthopedic Hospital. Prior to that, however, a letter
________________________: ________________ 48
that had been approved by the medical social worker was
sent to the parents or legal guardians of potential
subjects. The list of potential subjects was compiled
from the clinic files and approved by the social worker.
A copy of this letter appears in Appendix C.
From February to June of 1984, this researcher
attended the clinics at Orthopedic Hospital, obtained
informed consent from each subject's legal guardian.
Appendix D contains a copy of the subjects' Bill of
Rights and Form of Informed Consent. The MVPT was adminÂ
istered to each subject, and afterwards the subject's
chart was reviewed to obtain the previously enumerated
demographic details that were noted on the form in AppenÂ
dix A. A room was set aside for the researcher's use
during testing so that outside distractions were miniÂ
mized. The test was given to one child at a time accordÂ
ing to the instructions provided in the MVPT Manual by
Colarusso and Hammill (1972). Administration of the MVPT
took between 10 and 20 minutes, depending on the subject.
The researcher marked each selection made by the subject
on an answer sheet (see Appendix E). The subject's raw
score (the number of correct choices made of a possible
36) was determined and used in conjunction with the
child's age to obtain each subject's PQ. The PQs were
then used in the statistical analysis of the data. Both
___________________________________________________________ 49
the raw score and the perceptual quotients obtained are
presented in Appendix F.
Data Analysis
Demographic variables of age, gender, and diagnosis
were collected and used to develop descriptive categoriÂ
cal frequencies and statistics. Z tests were used to
assay the first two of the following null hypotheses and
a t test was used to assay the third.
1. Children with the neurological disorder of spina
bifida who have never been diagnosed as being hydroceÂ
phalic will not have statistically significantly lower
scores of visual perception when their scores on the MVPT
are compared to the normative population.
2. Children with spina bifida who have been diagÂ
nosed as also having hydrocephalus will not have statisÂ
tically significantly lower scores of visual perception
when their scores on the MVPT are compared to the
normative data.
3. Finally, the group of children with shunted
hydrocephalus with spina bifida will not have statistiÂ
cally significantly lower PQs on the MVPT than the group
of children with spina bifida who do not have
hydrocephalus.
Because the same data sets were used in both the _ t
test and the Z tests, a Bonferoni procedure was used to
__________________________________ 50
maintain an overall 95% level of significance (a = .05).
Thus, when statistical significance was found, .05 was
divided by the number of times those data sets were used,
making the resulting £ level necessary for significance.
The demographic information on the shunt history of
the subjects was tallied and used to answer the research
questions on the proportion of children with shunts on
the left side versus the right side of the head. It was
doubtful that a sufficient sample size of children with
shunts on the left would be gathered to answer the quesÂ
tion of whether there is a relationship between the side
of the head upon which a child is shunted and the occurÂ
rence of a greater amount of deficit in visual perceptual
abilities. Had the opportunity presented itself, an
independent sample t test at the .05 level of
significance was planned to analyze the means of the two
groups.
Methodological Assumptions
1. The MVPT measures a child's visual perception.
2. The MVPT is a valid measure for the purpose of
research.
Limitations
1. It was originally hoped that each subject's IQ
would have been available as part of the charted
---------- 5X-
information, but it was not. An analysis of covariance
was planned using IQ as the covariant to visual percepÂ
tion. This lack of covariance has become a limitation of
the study.
2. As mentioned in Chapter 1, requiring the volunÂ
tary consent of a subject means that the qualities of a
volunteer may in some way be different from those who
decline to participate in a given study. This could
possibly affect the generalization of the results of this
study to persons similar to those who rendered consent.
However, none of those approached for this study refused
to consent.
52
Chapter IV
RESULTS
A total of twenty-three 5 through 8-year-olds particÂ
ipated in this study. The average age of the particiÂ
pants was 7.43 years (7 years, 5 months). There were 9
female and 14 male subjects who had all been diagnosed as
having spina bifida with the level of lesion occurring in
the lumbar area of the spinal cord (L1-L5). Eight of the
subjects had been diagnosed as having only spina bifida
(that is, they did not have the complications of hydroÂ
cephalus) . Another 13 of the spina bifida subjects had
received shunts to control their hydrocephalus. Two of
the subjects had hydrocephalus which was considered to
have been self-arrested and thus these children had not
received shunts. Because there were only two subjects in
this category, they remain part of the data set as a
whole but are not a large enough sample to warrant statÂ
istical analysis as a separate group. Amazingly, both of
these subjects scored perceptual quotients of 100, the
exact mean of the normative data. A statistical summary
of this brief data set is therefore quite simple to
perform: it is 100 + 0.
__________ 53
Table 1
Perceptual
Diagnostic
Quotients and Summary Statistics
Spina Bifida Groups
for Three
Presence of
hydrocephalus
None With shunts No shunt
n = 8 n = 13 n = 2
96 66 100
100 78 100
107 83
110 89
111 90
112 92
114 92
116 95
98
98
105
112
124
Mean PQ = 108.3
Median = 110.5
No mode
SD = 6.9
Mean PQ = 94.0
Median = 92.0
Modes = 92, 98
SD = 14.7
Mean PQ = 100.0
Median = 100.0
Mode = 100
SD = 0
Results of the Research Hypotheses
All three research hypotheses were stated in a oneÂ
sided form, indicating directionality, due to the
empirical evidence presented in previous studies (Brunt,
1980; Miller & Sethi, 1971; Sand et al., 1973; Tew &
Laurence, 1975). The raw score as well as the perceptual
quotient of each subject are included in Appendix F. Z
54
tests were used to compare two of the groups to the
normative data (null hypotheses 1 and 2). The sample
groups were compared to the normative population with its
y (mean) of 100 and c r (standard deviation) of 15.
Hypothesis 3, comparing the two sample groups, was
evaluated with a t test. The results of these analyses
are summarized in Tables 2 and 3 while the alternative
hypotheses are presented below with the summary of the
statistical results.
1. Children with spina bifida who do not have
hydrocephalus will be more likely to have visual percepÂ
tual deficits than the normal population as evidenced by
statistically significantly lower PQ scores on the MVPT
(a = .025). (ot = .025 due to the use of the Bonferoni
procedure. To maintain an overall confidence level,
a = .05 is divided by the number of times the same data
set is used, twice in this case.) This one-sided hypothÂ
esis was not supported by the data analysis {Z = 1.56,
£ = .059, not significant).
2. Children with spina bifida who also have shunts
to control hydrocephalus will be more likely to have
visual perceptual deficits than the normal population as
evidenced by statistically significantly lower PQ scores
on the MVPT than the normal population (a = .025). This
55
Table 2
Z Test Analysis of Hypotheses 1 and 2
Groups compared Z, one-sided £ value
I. The spina bifida only
group to the normal
population 1.56 .059, NS
II. The hydrocephalis spina
bifida group with shunts
to the normal population .96 .169, NS
Table 3
t Test Analysis of Hypothesis 3
Groups compared T, one-sided £ value
III.Hydrocephalic spina bifida
group with shunts to spina
bifida group (no
hydrocephalus) 2.50 .01*
* a = .05 adjusted with Bonferoni
95% level of significance, a = .
significant at this level.
procedure. For
025; hypothesis
overall
3 is
one-sided hypothesis was not supported by the Z-test data
analysis (Z = .96, £ = .169, not significant).
3. The group of spina bifida children who have
shunted hydrocephalus will have statistically
56
significantly lower PQs on the MVPT than the group of
children who have spina bifida but not hydrocephalus
(a = .025). A pooled variance or independent sample t
test supported this hypothesis with a statistically
significant result (_t = 2.50, £ = .01).
Research Questions
Two research questions were also posed in addition to
the above hypotheses. The answers, based on the demoÂ
graphic information, turned out to be much more straightÂ
forward than was expected. The two questions were:
1. What is the proportion of children with hydroÂ
cephalus in the sample obtained for this study who
received shunts on the left side of the head to those who
received shunts on the right side?
2. Is there a relationship between the side of the
head upon which a child is shunted and the occurrence of
a greater amount of deficit in visual perceptual
abilities?
Since the answer to question #1 is that none of the
hydrocephalic children in this study were shunted on the
left side of the cranium (all 13 were shunted on the
right side) , it was not possible to assess the second of
the two questions.
57
Results of Additional Analysis
Because the results of hypotheses 1 and 2 were so
surprising, based on the expectations established by
previous research, it also made sense to look at the
distribution of the MVPT perceptual quotients of the
entire sample in comparison to the normal population. One
way to do this descriptively was to plot the PQ scores of
the spina bifida subjects on the normal curve as strucÂ
tured by the MVPT normative data (see Figure 2). Another
was to use the percentage information based on the normal
curve that leads to the expectation that 68% of a normal
population will fall between plus and minus one standard
deviation; 13.5% will fall between the minus one standard
deviation and the minus two standard deviation area as
well as between the plus one and plus two standard deviÂ
ation area; and 2.14% will fall between the minus two and
the minus three standard deviation area as well as
between the plus two and the plus three standard deviaÂ
tion area (see Figure 3). These anticipated score perÂ
centages were then used by visually comparing them to the
percentage of scores obtained by the study sample. This
comparison was done in histogram form presented in Figure
4.
A third way to analyze the data set as a whole, is to
compare it to the normal population via a Z test. In
___ 58
•• • •• • »
10
Figure 2. Subject perceptual quotients plotted against
MVPT normal curve.
Figure 3. Expected percentage delimitations of the
normal curve.
59
7 %
\^3U
Oof
156%
-3io-2 -2to-l —lto+1 +lto-»'2.
s ta m i> ad.d o ê v ia tiô m s
I I % expected based on normative data
% actually obtained from 23 spina bifida subjects
r ' ' - ~ 3
+ a tots
Figure Histogram comparison of expected perceptual
quotients versus percentage obtained from the sample.
this case, the null hypothesis being tested was that
children who have spina bifida will not have statistiÂ
cally significantly lower PQs on the MVPT than does the
normal population (a = ,05).
The alternative hypothesis that children who have
spina bifida will have statistically significantly lower
PQs on the MVPT than the normal population was not supÂ
ported by the data analysis = .07, p = .433, not sigÂ
nificant) . The PQs of the sample of children with spina
bifida were not statistically significantly lower than
60
those of the normal population as it was expected they
would be.
Conclusion
Neither the first two of the originally planned
hypotheses nor the fourth, stated above as an addendum,
were statistically supported. Instead, the data on the
entire spina bifida group look very similar to the normaÂ
tive data of 100 +15 with both a mode and median PQ score
of 100, a mean PQ score of 99.5, and a standard deviation
of 13.4. The data on the spina bifida group as a whole
also look visually quite normal both when individual
scores are plotted on the normal PQ curve and when
compared in histogram form (Figures 2 and 4) .
The third hypothesis was statistically supported,
even when the alpha level was adjusted from .05 to .025
by a Bovaronni procedure in order to maintain an overall
95% level of significance when the data were used more
than once. This indicates that MVPT perceptual quotients
in spina bifida children who have sufficient hydroÂ
cephalic complications to require shunting tend to be
significantly lower than those in the spina bifida chilÂ
dren who do not have hydrocephalus. Since all 13 members
of the spina bifida children in the shunted hydrocephalic
group had been shunted on the right side of the cranium
and none were shunted on the left side (Research Question
61
#1), it was not possible to determine any preliminary
surmises regarding possible relationships between the
side of the head shunted and the amount of visual
perceptual deficits exhibited (Research Question #2).
62
Chapter V
SUMMARY AND DISCUSSION
This last chapter reviews all that has come before
it. Also, the results are discussed in light of the
previous literature and the implications are then preÂ
sented. Finally, this presentation will conclude by
making recommendations for future research in this
subject area.
Summary
Purpose and Significance
The purpose of this study was to describe visual
perceptual abilities by using the MVPT of children 5 to 8
years old who have spina bifida lesion involvement in the
lumbar area of their spinal columns. The few previous
studies done in this topic area all led to the expectaÂ
tion that children with a diagnosis of spina bifida would
have a greater amount of perceptual deficits than were
found in the normal population of children in the same
age range.
The significance of such findings regarding a parÂ
ticular group's perceptual tendencies lies in the belief
63
that adequate perceptual abilities which involve the
recognition and differentiation of environmental stimuli
are a prerequisite to the satisfactory performance of
most of the activities that people routinely perform
throughout their daily lives. In humans, the visual
sensory systems provide one source of perception that is
of primary importance. Impaired perceptual abilities
impair ability to function in a person's surroundings
and, since it is an occupational therapist's task to aid
in the restoration of a persons functional capacity, it
is expected that the findings of this study are of
importance to them.
Review of the Literature
All of the literature reviewed in preparation for
this study indicated that children who have spina bifida
would be more likely than the population at large to
exhibit deficits in an area referred to as "visual perÂ
ception" and some studies made comparable predictions
regarding intelligence. One study by Tew and Laurence
(1973) compared intelligence test scores between patients
with spina bifida, their matched controls, and the sibÂ
lings of both groups. They found the IQ scores of the
spina bifida group to be lower and to have a wider spread
than the control group. They also found a statistically
significant difference of 26 IQ points between the 59
_________________________________________________ 64
spina bifida children and their 44 siblings (£ < .001);
no difference was found between the scores of the 57
control cases and their 63 siblings. Since the IQ scores
of the siblings of the spina bifida children, the control
children, and their siblings were virtually identical,
the examiners concluded that the lower IQ scores of the
spina bifida children did not reflect social class memÂ
bership, but rather maldevelopment of, or damage to, the
central nervous system. Tew and Laurence concluded this
1973 article by suggesting the prudence of taking into
account the intelligence of siblings when assessing a
child with spina bifida since it is generally expected
that children within a family will be in the same broad
band of intelligence. In respect to the present study,
the question of whether or not hydrocephalus was present
in the spina bifida group presents itself because this
researcher found a statistically significant difference
between the subject groups divided by whether or not they
had received shunts as a treatment for their hydrocephaus
(£ = .01). Tew and Laurence, in their 1973 study, did
not state how many, if any, of the spina bifida children
also had hydrocephalus.
Tew and Laurence published another study in 1975 in
which they studied the longitudinal effects of hydroÂ
cephalus on intelligence, visual perception, and school
__________________________________________ 65
attainment. Thirty-one of the 59 children with spina
bifida had been shunted, another eight had naturally
arrested hydrocephalus, and the other 20 presented no
clinical signs of hydrocephalus. Tew and Laurence (1975)
found the spina bifida group to have statistically sigÂ
nificantly lower scores on the IQ, perceptual, and acaÂ
demic achievement tests than did the group of matched
controls. Needless to say, it is hardly surprising that,
where deficit is found in perception, IQ scores and
academic achievement tests will also be affected. The
feat of separating out specific malfunctioning mechanisms
of the brain for evaluation is a multi-complex task:
intelligence tests tend to rely on the perceptual integÂ
rity of the individual, yet damage to the neuroanatomical
structures of the brain may be responsible for both
intellectual and perceptual deficits that have mutual
effects upon one another. Also, it is not clear what Tew
and Laurence (1975) mean when they refer to "the spina
bifida group." Do they mean the children who have spina
bifida only or do they mean the entire spina bifida group
both with and without hydrocephalus? Either way, it
could have an important impact on the results; it
certainly made a difference in this study.
A study by Miller and Sethi (1971) suggested a prevaÂ
lence of severe deficits in the perception of visuo-
' 66
spatial relationships among children with spina bifida.
Their sample size of 14 was exceptionally small and is
perhaps the reason these researchers also did not sepaÂ
rate out those who had hydrocephalus in addition to the
spina bifida, but included them all in one group of 14.
The findings by Sand, et al. (1973) indicated a tendency
for children with spina bifida to have significantly
lower than normal scores on the Frostig Developmental
Test of Visual Perception (DTVP). And while this study
used 37 subjects, the researchers categorized and recateÂ
gorized the data, enough times that it is very likely
that they have confounded it. Finally, Brunt (1980) made
some observations concerning the perceptual-motor perforÂ
mance in meningomyelocele children using the Southern
California Sensory Integration Tests (Ayres, 1974). He
concluded that they tended to demonstrate constructional
and gestural apraxia, lack of bilateral coordination, and
ataxia during upper extremity extension in a fine motor
task. Brunt used 41 meningomyelocele subjects, but only
six members of this group had never been diagnosed as
having hydrocephalus as well, and Brunt did not separate
them out as a group. Another consideration in this study
by Brunt, a member of the Physical Education Department
at Louisiana State University, is that although he did
obtain the services of a Registered Occupational
67
Therapist (OTR), nothing was mentioned about her qualifiÂ
cations in administering and interpreting the SCSIT.
These tests are intricate to administer and score and can
be complicated to interpret; therefore they require speÂ
cial knowledge and training to properly administer,
score, and interpret. Thus, it is assumed that if the
OTR in Brunt's study had acquired SCSIT certification, it
would have been stated. It is therefore assumed that the
absence of such a statement implies the absence of SCSIT
certification.
The Frostig DTVP (Frostig, Lefever & Whittley, 1966)
was used as the research instrument to assess "visual
perception" in three of the four above mentioned studies
that addressed visual perception in the spina bifida
population. Yet, the DTVP requires a greater amount of
processing and coordination from an organism (the child)
than merely visual perception as the test's title
implies. In fact, the very first subtest, called "Eye-
motor Coordination," involves drawing "continuous
straight, curved or angled lines between boundaries of
various widths, or from point to point without guideÂ
lines" (Frostig et al., 1966). The Frostig DTVP, it
seems, tests more than just the processing of visual
stimuli. Validity on the DTVP, other than face validity,
was based on its correlation with teacher ratings of
68
classroom adjustment in children. This, of course, sugÂ
gests the correctness of the hypothesis that disturbances
in what Frostig, as well as classroom teachers, are
calling "visual perception" are likely to be reflected in
disturbances in classroom behavior (Maslow et al.,
1964). Yet it seems to this researcher that what
teachers are evaluating and what Frostig is measuring
with the DTVP is a good deal more than just visual
perception.
There is, however, a test that is relatively free of
motor involvement from those being evaluated with it:
the Motor-Free Visual Perception Test (MTVP) by Colarusso
and Hammill (1972). This test was thoroughly reviewed in
Chapter 2 of this thesis. It was designed for use in
screening, diagnostic, and research purposes. It is
considered to be a quick, highly reliable, and valid
measure of overall visual perceptual processing ability
in children. Colarusso and Hammill (1972) agree that
perceptual tests which require a child to make compliÂ
cated graphic responses (the drawing of circles, squares,
straight lines, and other designs) confound their percepÂ
tual assessments with motor requirements. The MVPT was
thus the instrument of choice for this study.
69
Methods Reviewed
Z tests were used in this descriptive study
to analyze the two following one-sided hypotheses:
1. Children with spina bifida who do not have
hydrocephalus will be more likely to have visual percepÂ
tual deficits than the normal population within the same
age range as evidenced by statistically significantly
lower PQ scores on the MVPT.
2. Children with spina bifida who also have shunts
to control hydrocephalus will be more likely to have
visual perceptual deficits than the normal population.
This will be based on their MVPT PQ scores that will be
statistically significantly lower than those of the
normal population.
A t test was used to statistically analyze the third
research hypothesis:
3. The group of children with spina bifida who have
received shunts to control their hydrocephalus will have
statistically significantly lower PQ scores on the MVPT
than the group of children who have spina bifida but not
hydrocephalus.
Demographic information was collected on the shunt
location of the subjects. This information was used to
respond to the two research questions posed:
70
1. What is the proportion of hydrocephalic children
in the sample obtained for this study who were shunted on
the left side of the cranium versus those who were
shunted on the right side?
2. Is there a relationship between the side of the
head upon which a child is shunted and the occurrence of
a greater amount of deficit in visual perceptual
abilities?
An additional hypothesis concerning the entire sample
as a whole (N = 23) was later added to those
originally proposed:
4. Children who have spina bifida will have statisÂ
tically significantly lower PQs on the MVPT than does the
normal population of children within the same age range.
The sample used to test these hypotheses and answer
these questions consisted of 23 children between the ages
of 5 and 8 years from the general Southern California
area who had a diagnosis of spina bifida. The affected
area of lesion was the lumbar region on the spinal cord
(L^-Lg). These subjects were obtained through Orthopedic
Hospital of Los Angeles.
71
Results and Discussion of Their Significance
in Relation to the Previous Literature
in this Field
Results Reviewed
Quite unexpectedly, hypotheses 1, 2, and the addiÂ
tional 4 were not supported by the data. That is, the
spina bifida children did not differ significantly from
the normal population on the MVPT either when compared as
a whole group (4) or when divided according to the
absence or presence of hydrocephalus (1 and 2, respecÂ
tively). Hypothesis 3 stated that the shunted hydroÂ
cephalic spina bifida children would be statistically
significantly more likely to have visual perceptual defiÂ
cits than the group of spina bifida children who do not
have hydrocephalus. The difference between the PQs of
these two groups was found to be statistically signifiÂ
cant at £ = .01 in the predicted direction. This difÂ
ference was large enough that it remained statistically
significant even once the alpha level was adjusted from
.05 to .02 by a Bonferoni procedure, adjusting for
multiple use of the same data set.
The results of the research questions included the
discovery that all 13 of the shunted hydrocephalic parÂ
ticipants in this study were shunted on the right side of
the cranium; none were shunted on the left side, accordÂ
ing to the information in each subject's chart. It
72
therefore became impossible to assess the second of the
two research questions which asked if there were a relaÂ
tionship between the side of the head upon which a child
is shunted and the occurrence of a greater amount of
deficit in visual perceptual abilities.
Discussion of the Results of
Hypotheses 1, 2, and 4
All four of the hypotheses posed in this thesis were
based on the previous literature (Miller & Sethi, 1971;
Tew & Laurence, 1975). The findings in these studies all
indicated that children who had spina bifida would have a
statistically significant greater amount of perceptual
deficits than the normal population of same age children.
Previous studies (Sand et al., 1973; Tew & Laurence,
1975) also indicated that shunted, hydrocephalic spina
bifida children would have a statistically significant
amount of perceptual deficits than either the normal
population or the group of children with spina bifida
only (not hydrocephalus). The two aforementioned studies
even indicated that if one were to find cases of selfÂ
arrested hydrocephalus, they would lie between the other
two spina bifida groups (with shunt-treated hydrocephalus
and without hydrocephalus) in the amount of visual perÂ
ceptual deficits shown. Despite such overwhelming eviÂ
dence behind the predictions made in this study, no
___ 7 3
differences were found between the spina bifida group as
a whole (n = 23) and the normative population; nor was it
found between: 1. the spina bifida only group (n = 8),
2. the self-arrested hydrocephalic spina bifida group
(n = 2), nor 3. the shunted hydrocephalic spina bifida
group (n = 13) and the normative population.
How could there be such a discrepancy between the
previous research (several studies) and this one study?
There are, in fact, several possibilities. Perhaps the
small sample size in either this or the other studies has
not yielded an accurate representation of the actual
spina bifida population. Because this study, as well as
the others, has utilized a sample of convenience rather
than a random sample, perhaps we each have a different
sample segment of the spina bifida population. However,
because Orthopedic Hospital is located in an area of Los
Angeles of lower socioeconomic status and this tends to
be associated with lower than average IQ scores, it is
not likely that this researcher happened to assess a
sample of the spina bifida population of above-average
intelligence and thus obtain above-average or aboveÂ
expected PQs on the MVPT. Or perhaps a more interesting
and satisfactory explanation of these differences may lie
behind the instrument of choice in each of the different
studies.
-------------------------------------------------------- ZiJ
A major difference between this study and the preÂ
vious ones is the instrument being used to evaluate what
is being called "visual perception" in all the articles.
The Frostig DTVP was the instrument of choice in three of
four previous studies on perceptual processing in spina
bifida children that were cited earlier, while the MVPT
by Colarruso and Hammill was the instrument of choice in
this study. In both of these tests, the initials "V.P."
stand for "Visual Perception;" yet perhaps they are not
both a measure of the same process, for one of them
requires a great deal more motor output and coordination
than does the other. As was mentioned earlier in this
chapter, the DTVP requires the child being evaluated to
make relatively complicated graphic responses (the drawÂ
ing of circles, squares, straight lines, and other
designs) while the MVPT does not (it requires only the
ability to organize motor output to that of a pointed
finger).
The DVPT is an older instrument than the MVPT and
when it was first developed it was a much needed tool.
It also makes sense that Marianne Frostig, whose backÂ
ground was child education, would see writing, drawing,
and copying deficits as direct results of deficits in
"visual perception." And it also seems reasonable that
deficits in visual perception would and do interfere with
____________ 75
both fine motor (writing, copying, drawing, pen and penÂ
cil tasks) and gross motor performance levels. Yet, it
does not necessarily follow that all deficits in motor
output are results of visual perceptual deficits. There
are bound to be cases where uncoordinated movements,
ataxia, and apraxia stem from an impaired motor output
system (exemplified upper motor neuron damage as in the
case of cerebral palsy) or an impaired sensory system
other than the visual sensory system such as deficits in
proprioception, kinesthesia, stereognosis or light touch.
In other words, the human brain and the process by which
it interacts with the environment is so complex that
evaluating visual perception by requiring motor output
may in some cases confound all attempts for accuracy. It
should be obvious how this may be the case in children
with cerebral palsy, but perhaps it has not been so
obvious in the case of the child with spina bifida.
The neurological deficits, both sensory and motor,
that the spina bifida child experiences below the level
of lesion in the spinal column are usually obvious (such
as lower extremity paresis or paralysis), though the
severity may vary in individuals, depending upon the
extent of the neural tube damage. Yet it seems to have
been assumed in the treatment of these children that,
like the spinal cord injured patient, they are sensorily
_____ 76
intact above their level of neurological involvement. If
this assumption were made and a child having spina bifida
appeared to be moving his upper extremities in an uncoÂ
ordinated, apraxic fashion, it might then be assumed that
that child's problem in skilled upper extremity movement
was the result of a visual perceptual deficit. And
should that child be evaluated by an instrument such as
the DTVP which requires coordinated, upper extremity
motor planning and output, that child would indeed be
termed as "perceptually impaired." But what if the
impairment were in the area of upper extremity sensation
such as proprioceptive, kinesthetic, stereognosia, or
light touch abilities and not visual perception? And
could this idea be taken one step farther? Could it be
possible that people with spina bifida may even use
visual perception to ompensate for other sensory deficits
that, when tsted as "perceptual-motor," also interfered
with that person's motor interactions with the environÂ
ment. If such were the case, it seems as though an
instrument such as the MVPT is a truer measure of visual
perception than is an instrument requiring motor output
to measure a visual processing system such as the DTVP.
Yet, while a motor-free assessment may indeed be a
more accurate measure of visual perception than one
requiring motor-output, a discrepancy between two such
_________ 77
tests may indicate the need for further assessments to be
made on the client's behalf. Such assessments should
include the aforementioned aspects of the sensory system:
proprioception, kinesthesia, stereognosis, graphesthesia,
and light touch. Unfortunately, an accurate assessment
of all of these areas in conjunction with the quality of
client's motor output would be both complex and time
consuming to administer, score, and interpret. Indeed,
such is the case with the battery of tests known as the
Southern California Sensory Integration Tests developed
by Ayres (1974). Jean Ayres has recognized for years the
complexity of the processes in the central nervous system
that must connect in order for a human being to successÂ
fully interact with his environment (Ayres, 1964, 1965,
1980). Dr. Ayres realized years ago that an adaptive
response to environmental demands (e.g., successful motor
output) requires as a prerequisite the internal organizaÂ
tion of many sensory systems: visual, vestibular, tacÂ
tile, proprioceptive, kinesthetic, and stereonosia.
Thus, Ayres' theory of sensory integration recognizes and
addresses the complex prerequisites required for a human
organism to achieve successful motor output (what she
calls an adaptive response) through successfully organizÂ
ing or integrating many accurately perceived sensations
or input (Ayres, 1980). Based on her complex neuro-
_____________ 78
developmental theory. Dr. Ayres developed the SCSIT, a
complex series of tests that assess both sensory processÂ
ing and motor output (Ayres, 1974). Sensory integrative
theory then provides the structure for treating sensory
integrative disorders as they are diagnosed by interÂ
preting a child's scores on the SCSIT as well as through
clinical observations (Ayres, 1980).
The point of the aforementioned discussion is that,
while the MVPT may be a more valid assessment of visual
perception than the DTVP, the implication behind a perÂ
ceptual test requiring motor output (such as the DTVP) is
that what is important to the child is successful interÂ
action with the environment as measured by motor output.
In other words, it is through motor output that adaptive
responses (i.e., successful interactions with the enviÂ
ronment) are made possible; yet adaptive motor responses
require constant and accurate sensory readings (percepÂ
tion and integration) of one's environment. Therefore a
test such as the DTVP may accurately discern a child's
difficulty in adaptively responding to some of the fine
motor demands of his role requirements. And while this
child's difficulty may indeed stem from visual perception
deficits, it is this researcher's opinion that the DTVP
confounds the assessment of such skills by requiring
additional demands of motor involvement from the child
____________________________________________________________79
while the MVPT does not. Yet, while the MVPT may be a
more valid measure of visual perception than the DTVP, it
yields very little useful information to either the
researcher or the clinician regarding a person's ability
to successfully interact with his environment. It thereÂ
fore seems to this researcher that not only is the adminÂ
istration of both the MVPT and the DTVP useful to more
accurately assess a child's visual perception as well as
his ability to coordinate fine motor responses to percepÂ
tual demands, but that the SCSIT, a more complex assessÂ
ment tool, is perhaps the most appropriate measurement
presently available to evaluate the complex workings of
the central nervous system. Yet the major drawback in
using the SCSIT is their very complexity: the precise
way they must administered, the amount of time necessary
to give, score, and interpret the tests, and the wealth
of knowledge in sensory integrative theory required to
accurately interpret the test scores as well as to plan a
therapeutic program of remediation requires special
knowledge and training. The clinician must therefore
gauge the best use of his evaluation time and effort in
relation to the degree and amount of accurate assessments
required in each instance of client evaluation. Yet, it
may well be worth this increased diagnostic effort on
behalf of the spina bifida client to establish the more
80
subtle aspects of central nervous system involvement in
his or her interactions with the environment.
Other implications that this research may hold for
the field of occupational therapy as well as for other
related disciplines is the overwhelming need for the
clarification of terms regarding the phrases: "visual
perception," "perceptual-motor," and "sensory integraÂ
tion." This researcher is aware of a chapter by Clark,
Mailloux, and Parham to a textbook currently in press
which seeks to clarify these phrases in terms of the type
of treatment process provided. However, it is also
necessary for us, as clinicians, researchers, and educaÂ
tors, to create more precise operational as well as
theoretical definitions of the phrases: "visual
perception," "perceptual motor," and "sensory
integration."
Discussion and Implications of the
Results of Hypothesis 3 and
the Two Research Questions
The third hypothesis tested in this study predicted
that the group of spina bifida children who had been
shunted to control their hydrocephalus would have a staÂ
tistically significantly lower PQ scores on the MVPI than
the group of children who have spina bifida but not
hydrocephalus. This hypothesis was supported by the data
analysis with a 95% level of confidence (£ = .01). It,
81
like the others, was suggested by the previous research
that had been done using the DTVP to assess "visual
perception" in children who had a diagnosis of spina
bifida. The implication of this finding in conjunction
with the previously mentioned studies is that children
with spina bifida who have received shunts as a treatment
for their hydrocephalus are more likely to have a greater
amount of both visual perceptual and perceptual motor
deficits than children with a diagnosis of only spina
bifida. If this is the case, then it must be remembered
that no cause-and-effeet status has been shown regarding
a relationship between a child having a shunt and an
increased tendency to have visual perceptual or percepÂ
tual motor deficits. The finding may instead be related
to the hydrocephalic process itself impinging upon brain
cells or to some other process not yet determined.
It was hoped that the two research questions posed in
this study would help to provide some insight into the
matter of a possible association of shunted hydrocephÂ
alus, the side of the head shunted, and the presence of
visual perceptual deficits. The suspicion was that
hydrocephalic children who had been shunted on the right
side of the head might display a greater amount of visual
perceptual deficits when assessed by the MVPT than hydroÂ
cephalic children who had been shunted on the left side,
82
and research question #2 was formulated to assess this.
However, since the shunting procedure is performed much
more frequently on the right side (all those with shunts
in this study had it done on the right), it was deemed
necessary to determine the ratio of those hydrocephalic
participants in this study who had been shunted on the
left to those who had been shunted on the right (research
question #1). Since the ratio turned out to be 0:13, it
was not possible to assess the second research question.
Research questions #1 and #2 still remain, therefore, as
possible ideas for future research in this subject area.
What did surface, however, was an observation that 13 of
the 23 subjects with spina bifida had shunts to control
their hydrocephalus, that is, 57% of this sample. Yet in
1976 Brocklehurst reported that only 10% to 15% of chilÂ
dren with spina bifida did not have shunts, indicating
that 85% to 90% of spina bifida children had indeed had
shunts to control their hydrocephalus. The implication
is either that this sample is not representative of the
population as a whole, or that only 8 years later fewer
children are receiving shunts than previously, or that as
the children get older, more of them may require shunts
and that if a wider age range of people with spina bifida
wre sampled, Brocklehurst's epidemiological data may
still be accurate today.
____________________________________________________________83
Overall Implications A££ectii^
the Spina Bi£ida Client
Due to the highly complex nature of the central
nervous system and its importance in a person's successÂ
ful interaction with the environment, the impact of a
neural tube disorder may be so multifaceted that it
becomes an extremely complex process to evaluate all
aspects of its effects on a child and his family. As was
previously mentioned (in Chapter 2), the task of separatÂ
ing out specific malfunctioning mechanisms of the central
nervous system for evaluation and treatment is indeed
complex. Intelligence tests tend to assume the percepÂ
tual integrity of all sensory systems on the part of the
subject tested; fine and gross motor skills are also
often the means by which visual perceptual, perceptual-
motor, and intelligence tests are measured. A deficit in
any one of these areas of the system will affect the
performance level of all the other areas and of the
system as a whole. It is therefore essential for an
occupational therapist, on behalf of the client, to be
able to accurately evaluate and define the problem
area(s) as this is a prerequisite to attempts at remediÂ
ation of a client's consequential decreased role perforÂ
mance. Thus, professional agreement in the health and
special education related fields on the theoretical as
well as the operational definitions of terms related to
________________ 84
sensory perception, its organization in terms of adaptive
responses (motor output) is essential for many reasons:
1. Quality care for clients.
2. Accurate, valid, and reliable assessment tools
for diagnostic as well as research purposes.
3. A clear understanding by all professionals as to
what is meant by each of many complexly related concepts.
Limitations of this Study
1. IQ scores were not used as a covariant to MVPT
scores as was originally planned.
2. Only one measurement of visual perception was
used.
3. The subjects in this study were not matched to a
control group, instead the normative data on the MVPT
were used in comparison to the spina bifida subjects.
4. The sample size of this study was limited to 23.
Implications for Future Research
Some suggestions for future research have already
been stated in the discussion and implication sections of
this chapter. One such suggestion is the immediate need
in occupational therapy and other related fields for the
clarification of such phrases as "visual perception,"
"perceptual-motor," and "sensory integration." Not only
do such terms need to be more precisely defined with
85
widely agreed upon definitions, but the assessment tools
used to evaluate such conditions need to be reassessed
operationally in conjunction with the theoretical definiÂ
tions. As was previously mentioned, Clark, Mallioux, and
Parham (in press) have delineated treatment programs in
reference to the aforementioned terms, but more clarifiÂ
cation is still needed in this area.
Perhaps one way to achieve both the task mentioned
above and to obtain more information regarding the
perceptual-motor/sensory integrative functioning of spina
bifida children would be to duplicate this study using
several evaluation tools, such as the MVPT, the DTVP, and
the sections of the SCSIT that it is possible to perform
within the abilities of the spina bifida child.
Also, this researcher was unable to obtain a sample
of children with hydrocephalus who have shunts on the
left side rather than on the right side (the more common
procedure). Thus the research question posed in this
study has yet to be addressed in the literature: Are
there a greater amount of visual perceptual deficits in
those who are shunted on the right side of the cranium
than in those who are shunted on the left side in the
treatment of hydrocephalus?
86
Coficlasion
In this, the fifth chapter of this paper, a summary
of the previous chapters was provided. The results of
the data analysis were discussed as were the implications
drawn from the results. Finally the limitations of this
thesis were stated and recommendations for future
research were made.
87
REFERENCES
88
Ayres, A. J. Tactile functions: Their relation to
hyperactive and perceptual motor behavior. American
Journal of Occupational Therapy, 1964, 6-11.
Ayres^ A. J. Patterns of perceptual-motor dysfunction in
children: A factor analytic study. Perceptual and
Motor Skills, 1965, 20, 335-368.
Ayres, A. J. Southern California sensory integrative
test manual. Los Angeles: Western Psychological
Services, 1974.
Ayres, A. J. Sensory integration and the child. Los
Angeles: Western Psychological Services, 1979.
Ayres, A. J. Sensory integration and learning disorders.
Los Angeles: Western Psychological Services, 1980.
Azen, S. P. Class lecture. University of Southern
California, October 1982.
Bigge, J . , & Sirvis, B. Children with physical and
multiple disabilities. In N. G. Haring (Ed.),
Behavior of exceptional children, (2nd ed.).
Columbus: Charles E. Merrill Publishing Co., 1978.
Brocklehurst, G. (Ed.) Spina bifida for the clinician.
Philadelphia: J. B. Lippincott Co., 1976.
Brunt, D. Characteristics of upper limb movements in a
sample of meningo-myelocele children. Perceptual
Motor Skills, 1980, 51(2), 431-437.
Clark, F., Mailloux, Z., & Parham, D. (In press).
Learning disabilities and occupational therapy. In
A. Allen and P. N. Clark (Eds.), Occupational therapy
for children— A comprehensive textbook. St. Louis:
C. V. Mosby.
Colarusso, R.P., Hammill, D. D. Motor-free visual
perception test manual. Novato, CA: Academic
Therapy Publication, 1972
Eccles, J. C. The understanding of the brain. New York:
McGraw-Hill Book Co., 1977.
Emery, J. L., & Svitok, I. Interhemispherical distances
in congenital hydrocephalus associated with
meningomyelocele. Developmental Medicine and Child
Neurology, 1968, 3^, 21.
___________ 89
Frostig, M., Lefever, D., & Whittlesey, J. Developmental
test of visual perception. Perceptual and Motor
Skills, 1964, 463-499.
Frostig, M., Lefever, D., & Whittlesey, J. AdministraÂ
tion and scoring manual for the Marianne Frostig
Developmental Test of Visual Perception. Palo Alto,
CA: Consulting Psychologists Press, 1966.
Grimm, R. A. Hand function and tactile perception in a
sample of children with myelomeningocele. American
Journal of Occupational Therapy, 1976, 30, 234-240.
Hole, J. W., Jr. Human anatomy and physiology. Dubuque:
Wm. C. Brown Co., Publishers, 1978.
Lewin, R. Is your brain really necessary? Science,
1980, 23^, 1232-1234.
Lorber, J. Systematic ventriculographic studies in
infants born with meningomyelocele and encephalocele.
The incidence and development of hydrocephalus.
Archives of Disease in Childhood, 1961, 36, 381.
Lorber, J., & Bassi, U. The etiology of neonatal
hydrocephalus (excluding cases with spina bifida).
Developmental Medicine and Child Neurology, 1965, 7,
289-294.
Miller, E., & Sethi, L. The effect of hydrocephalus on
perception. Developmental Medicine and Child
Neurology, 1971, 33, Suppl. 25.
Roaf, R. Spinal deformities. Philadelphia: J. B.
Lippincott Co., 1977.
Sand, P. L., Taylor, N., & Hill, N. Hand function in
children with myelomeningocele. American Journal of
Occupational Therapy, 1974, 87-90.
Sand, P. L., Taylor, N., Rawlings, M., & Chitnis, S.
Performance of children with spina bifida manifesta
on the Frostig developmental test of visual
perception. Perceptual Motor Skills, 1973, 3T7, 539-
546.
Seligman, J. Saving spina bifida babies. Newsweek,
November 15, 1982.
90
Slâman, J. The cross cultural validity of the Ayres
figure ground test. Unpublished thesis proposal,
University of Southern California, 1982.
Siev, E., & Preishtat, B. Perceptual dysfunction in the
adult stroke patient: A manual for evaluation and
treatment. Boston: Charles B. Slack, Inc., 1982.
Tew, B., & Laurence, R. Mothers, brothers and sisters of
patients with spina bifida. Developmental Medicine
and Child Neurology, 1973, 15(6) , Suppl. 29.
Tew, B., & Laurence, R. The effects of hydrocephalus on
intelligence, visual perception and school
attainment. Developmental Medicine and Child
Neurology, 1975, ^(6), Suppl. 35, 129-134.
Thomas, C. L. Taber's cyclopedic medical dictionary (14th
ed.). Phildelphia: F. A. Davis Company, 1981.
Villani, R., Giani, S. M., Giovanelli, M., Tomei, G.,
Zavanone, M. L., & Motti, E. D. F. Skull changes and
intellectual status in hydrocephalic children
following CSF shunting. Developmental Medicine and
Child Neurology, 1976, 18(6), Suppl. 37, 77-81.
Warkany, J., & O'Toole, B. A. Experimental spina bifida
and associated malformations. Child's Brain, 1981,
8(1), 18-30.
Wealthall, S. R. An investigation of the factors involved
in regulating ventricular size and the production of
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Publications, 1973.
91
APPENDIX A
Demographic Information Sheet
92
Janet Supowitz
University of Southern California
Occupational Therapy Student
Demographic Information
I.D.__________________ __________
Age ____________
Yr. Mo.
Sex (M=l, P=2) _____
IQ t test:
Related Medical Information
Level of spinal lesion ___________
Has this area ever been operated on? _____
(No=ly Yes=2)
How many times? _____
Has hydrocephalus ever been diagnosed? ___________
(No=l, Yes=2)
Shunt History
Is the child presently shunted?__________________
(No=l, Yes=2)
Is the shunt currently functioning ?________ _____
(No=l, Yes=2, Don't know=3)
On what side is the child's present shunt? _____
(Right=l, Left=2)
Has the shunt always been on that side? _____
(No=l, Yes=2)
Number of times on the R side? _____
Number of times on the L side? _____
How many shunts has the child had
(including the present one)?________________________
How many shunt related operations has
the child had?_______________________________________
Number on the R side? _____
Number on the L side? _____
Other relevant medical information:
93
APPENDIX B
Orthopedic Hospital Letter of Approval
94
OrthopædicHospita!
2 400 S o u th flo w e r S tre v '
L o s A n y e te s . C a n to r r u d SOOCT
T e le p h o n e : 2 1 3 '7 4 2 ^ 1 0 0 0
M a tf in g A d a r e s s
P .O . B o x 6 Ü 1 32 . T e r n r n a i A n n e x
Lor> A n g e le s C a n fn m ia 900^*^
December 2 2 , 1983
Bone S Connective
Tissue Research Program
Ms. Jan et S upow itz
12536 Ryerson A ve. #26
Downey, C a l i f . 90242
Dear Ms. S u p o w itz,
The IRB a t i t s m e etin g on December 12, 1983
approved you r p ro p o s a l e n t i t l e d " V is u a l P e rc e p tio n
in C h ild re n 6 to 8 Years O ld W ith a D ia g n o s is o f
S pina B if id a " . The in fo rm ed consent was approved
and no r is k f a c to r a s s ig n e d .
S in c e r e ly ,
M e lv in S t o l t z , M .D .
C hairm an, IR B -R esearch
Com m ittee
A J o in t P / c a ia m c l
O n h o o a c c h c H o o p iia i
a n a th e U n iv e rs ity
o l S o u th e rn C a h io m ia .
95
APPENDIX C
Letter to Guardians of Potential Subjects
96
. T t f i w r r S o e ^ '
I os Ao'jt’fes.Cacro^n a yjOO'
feieonono 2i3-74J-:0‘'\'
Md'tng A a o r e s ^
P O. B e x 6 0 t ? 2 , T e r m in â t Artnex
OrthopsBOicHospitr^! lus ^
D ear P a re n t o r G u a rd ia n ,
I am w o rkin g on my th e s is f o r a M a s te r 's D egree in occuÂ
p a t io n a l th e ra p y a t th e U n iv e r s ity o f S o u th ern C a l i f o r n i a . I
am in te r e s te d in how o c c u p a tio n a l t h e r a p is ts can b e t t e r h e lp
c h ild r e n who have a d ia g n o s is o f s p in a b i f i d a , e s p e c ia lly in
th e a re a o f v is u a l p e r c e p tio n . You and you r c h ild can be o f
g r e a t h e lp to me w ith t h is g o a l by a llo w in g me to work w ith
you r c h ild f o r abo u t h a lf an h o u r, d u rin g w hich we w ould p la y
some v is u a l games.
O rth o p e d ic H o s p ita l has* b oth approved my p r o je c t and been
h e lp in g me w ith i t . Y o u 're c o o p e ra tio n would le a d to knowledge
t h a t would h e lp p r o fe s s io n a ls in t r e a t in g c h ild r e n who have s p in a
b i f i d a . A ls o , you r c h ild may b e n e f it in a more d i r e c t way from
th e r e s u lt s o f th e v is u a l screen t h a t w i l l be g iv e n as I w i l l be
g la d to d is cu s s th e s e r e s u lt s w ith you and what th e y may mean f o r
yo u r c h ild .
I w i l l be c o n ta c tin g you s h o r t ly , e it h e r a t c l i n i c o r by
phone. Thank you f o r your c o o p e ra tio n .
S in c e r e ly ,
J a n e t Supow itz
97
APPENDIX D
Subjects* Bill of Rights
Form of Informed Consent
98
HEQICAt RESEARCH PROJECT: MINORS
P a r t i c i p a n t 's B i l l o f R ig h ts C o ncern in g M e d ic a l R esearch
P r o je c ts
The l i s t i n g w h ich fo llo w s c o n s titu te s a b i l l o f r i g h t s conÂ
c e rn in g m in o rs who nay p a r t i c ip a t e in a m e d ic a l r e s e a rc h
p r o je c t b e in g co n d u cted a t O rth o p a e d ic H o s p ita l.
The te rm " m e d ic a l r e s e a rc h p r o je c t " r e f e r s o n ly to m e d ic a l
e x p e rim e n ts w h ich a r e r e la t e d to m a in ta in in g o r im p ro v in g
th e h e a lt h o f th e m in o r p a r t ic ip a n t in th e m e d ic a l re s e a rc h
p r o je c t , o r r e la t e d to o b ta in in g in fo r m a tio n a b o u t a p a t h o lÂ
o g ic a l — i . e . , d is e a s e — c o n d itio n o f th e m in o r p a r t ic ip a n t ,
The O rth o p a e d ic H o s p it a l, w it h re s p e c t to m e d ic a l re s e a rc h
p r o je c t s , asks a l l p a r t ic ip a n t s (o r t h e i r p a r e n ts , g u a rd ia n s
o r o th e r le g a l r e p r e s e n t a t iv e s ) to c a r e f u l l y re a d and u n d e rÂ
s ta n d th e fo llo w in g p a r t i c i p a n t 's b i l l o f r ig h t s :
- To be in fo rm e d o f th e n a tu re and purpose o f a
m e d ic a l r e s e a rc h p r o je c t .
- To be g iv e n an e x p la n a tio n o f th e p ro c e d u re s to be
fo llo w e d i n a m e d ic a l re s e a rc h p r o je c t , and o f any
drug o r d e v ic e to be u t i l i z e d .
- To be g iv e n th e o p p o r tu n ity to d e c id e to c o n s en t o r
n o t to c o n s en t to a m e d ic a l re s e a rc h p r o je c t - - i . e .
a m e d ic a l e x p e rim e n t - - w ith o u t th e in t e r v e n t io n o f
any e le m e n t o f f o r c e , fr a u d , d e c e it, d u re s s , c o e rÂ
c io n , o r undue in flu e n c e on th e p a r t ic i p a n t 's d e c iÂ
s io n .
- To be g iv e n an o p p o r tu n ity to a sk any q u e s tio n s
c o n c e rn in g th e m e d ic a l re s e a rc h p r o je c t o r th e
p ro c e d u re s in v o lv e d .
- To be g iv e n an e x p la n a tio n o f any b e n e fits to th e
p a r t ic ip a n t re a s o n a b ly to be exp ected fro m th e
m e d ic a l r e s e a r c h p r o je c t .
- To be g iv e n a d e s c r ip tio n o f any a tte n d a n t discom Â
f o r t s o r r is k s re a s o n a b ly to be e xp ec ted fro m th e
m e d ic a l r e s e a rc h p r o je c t .
- To be g iv e n a d is c lo s u r e o f any a p p r o p r ia te a l t e r n a Â
t i v e p ro c e d u re s , drugs o r d e v ic e s th a t m ig h t be
advan tag eo u s to th e p a r t ic ip a n t , and o f th e r e l a t i v e
r is k s and b e n e f it s o f such a lt e r n a t iv e p ro c e d u re s ,
d ru g s , o r d e v ic e s .
99
MEDICAL RESEARCH PROJECT: MIsOHS
P a r t i c i p a n t 's B i l l o t R ig h ts ric e rn in g M e d ic a l R esearch
P r o je c ts
- To be in fo rm e d o f th e avenues o f m e d ic a l tr e a tm e n t,
i f a n y , a v a ila b l e to th e p a r t ic ip a n t a f t e r th e
m e d ic a l re s e a rc h p r o je c t i f c o m p lic a tio n s sh o u ld
a r is e fro m p a r t ic ip a t io n i n th e p r o je c t .
- To be in s tr u c te d t h a t consent to p a r t i c i p a t e in th e
m e d ic a l re s e a rc h p r o je c t may be w ith d ra ifn a t any i
tim e and th e p a r t ic ip a n t may d is c o n tin u e such p a r t i - |
c ip a t io n in th e m e d ic a l re s e a rc h p r o je c t w ith o u t
p r e ju d ic e .
^ To be g iv e n a copy o f th e p a r t ic ip a n t 's s ig n e d and
d a te d w r i t t e n con sen t fo rm c o n c e rn in g p a r t i c i p a t i o n
in a m e d ic a l re s e a rc h p r o je c t .
The d a tin g and s ig n in g o f t h is " P a r t i c ip a n t 's B i l l o f R ig h ts
C o n cern in g M e d ic a l R esearch P r o je c ts " by a p a r e n t, g u a rd ia n ,
o r o th e r le g a l r e p r e s e n t a t iv e o f th e m in o r p a r t i c ip a n t
acknow ledges t h a t p e rs o n 's r e c e ip t o f a copy o f t h i s b i l l o f
r ig h t s b e fo r e t h a t p erso n has con sen ted th a t a named m in o r
p a r t ic ip a t e i n a m e d ic a l re s e a rc h p r o je c t — i . e . , a m e d ic a l
e x p e rim e n t - - a t O rth o p a e d ic H o s p it a l.
The m in o r p a r t i c i p a n t 's p a r e n t, g u a rd ia n o r o th e r le g a l r e p r e Â
s e n t a t iv e acknow ledges t h a t he is f lu e n t in t h e ________ _______
la n g u a g e , b e in g th e lan g u a g e used to s e t f o r t h t h i s b i l l o f
r ig h t s .
D a te d : 19
S ig n a tu re o f m in o r p a r t ic i p a n t 's
p a r e n t, g u a rd ia n o r o th e r le g a l
r e p r e s e n t a t iv e .
P r in te d name o f p a r e n t, g u a r-
d ia n , o r o th e r le g a l re p re s e n Â
t a t i v e
P r in te d name o f m in o r p a r t i c i -
p a n t in th e m e d ic a l re s e a rc h
p ro j e c t
100
INFORMED CONSENT FORM: MEDICAL RESEARCH PROJECT
1.
SUBJECT*S tlAME: OPD No.
2.
T IT L E OF PROJECT: VISUAL PERCEPTION IN CHILDREN
3.
PURPOSE OF PROJECT: To exam ine i f t h e r e 's an a s s o c ia tio n betw een *
S p in a B if id a and v is u a l p e r c e p tio n .
4. PROCEDURE FOR PROJECT: (M u st in c lu d e d is c u s s io n o f a n y p o s s ib le
u s e o f a p la c e b o .) A d m in is tr a tio n o f a m o to r -fr e e v is u a l p e r c e p tio
t e s t (th e M V P T).
'
5. BENEFITS THE PARTICIPANT MAY REASONABLY EXPECT:
A q u ic k s c re e n in g o f h is /h e r v is u a l p e r c e p tu a l s k i l l s .
-
6. ATTENDANT RISKS AND DISCOMFORT THE PARTICIPANT MAY REASONABLY
EXPECT: 2 0 -3 0 m in u tes o f h is /h e r tim e . -
-
7.
AVAILABLE AND APPROPRIATE ALTERNATIl'E PROCEDURES, DRUGS
DEVICES THAT M IGHT BE ADVANTAGEOUS TO THE P A R TIC IPA N T:
None
OR
8. BENEFITS THE PARTICIPANT MAY REASONABLY EXPECT FROM THE ALTERNAÂ
T IV E PROCEDURES, DRUGS OR DEVICES: '
9. RISKS THE PARTICIPANT MAY REASONABLY ASSUME W ITH RESPECT TO THE.
ALTERNATIVE PROCEDURES. DRUGS OR DEVICES:
1 0 1
INFOR>îED CONSL'iii fv .v .
1 0 . ESTIMATE OF THE PA R TIC IPA N T'S EXPECTED RECOVERY TIME AFTER COM-'
PLETION OF H IS PA RTICIPATIO N IN THE MEDICAL RESEARCH PROJECT:
N o n e n e e d e d .
1 1 . NAME OF SPONSOR OR FUNDING SOURCE, I F ANY, OF THE MEDICAL
RESEARCH PROJECT:_________ K°ne ._________________ ^ ___
1 2 . NAME OF MANUFACTURER OF ANY DRUG OR DEVICE INVOLVED IN THE MEDÂ
IC A L RESEARCH PROJECT;
1 3 . NAÃŽ'ÃŽE OF ORGANIZATION, I F ANY, UNDER WHOSE GENERAL AUTHORITY THE
MEDICAL RESEARCH .PROJECT IS BEING CONDUCTED: O c c u p a tio n a l T h erap y
D ep artm en t o f U -S .C . / O rth o p a e d ic H o s p ita l
1 4 . NAME. IN S TITU TIO N A L A F F IL IA T IO N . I F ANY, AND ADDRESS OF PERSON(S)
ACTUALLY PERFORMING AND PRI2IARILY RESPONSIBLE FOR THE CONDUCT OF
â– THE MEDICAL RESEARCH PROJECT:______ J a n e t S u p o w itz , USC M asters
S tu d e n t in O c c u p a tio n a l T h e ra p y . 12536 Ryerson Ave #26
Downey, C a l i f . 90242
102
INFORiED CONSENT FORM: MEDICAL RESEARCH PROJECT
S ta te m e n ts by th e P a r t i c i p a n t i n th e M e d ic a l R e s e a rc h P r o te c t, o r
by h is A u th o r iz e d L e g a l R e p r e s e n ta t iv e :
- - I h a v e b e e n p r o v id e d w it h a copy o f th e " P a r t i c ip a n t 's B i l l
o f R ig h ts C o n c e rn in g M e d ic a l R es ea rc h P r o je c t s " b e fo re c o n Â
s e n tin g to p a r t i c i p a t i o n i n t h i s m e d ic a l r e s e a r c h p r o j e c t - -
i . e . , t h i s m e d ic a l e x p e r im e n t.
— I h a v e r e c e iv e d u n d e r s ta n d a b le answ ers t o a l l my q u e s tio n s
c o n c e rn in g t h i s m e d ic a l r e s e a r c h p r o je c t and th e p ro c e d u re s
in v o lv e d t h e r s i n - - a n d a l l such ans^;ers a r e c o n s is te n t w it h
th e s ta te m e n ts and in f o r m a t io n in . t h i s w r i t t e n , c o n s e n t f o r m . i
- - I f u l l y u n d e r s ta n d t h a t p a r t i c i p a t i o n in t h i s m e d ic a l r e s e a r c h =
p r o j e c t i s v o l u n t a r y . To th e b e s t o f my k n o w le d g e , t h is c o n Â
s e n t to p a r t i c i p a t e was g iv e n i n th e c o m p le te absence o f a n y
e le m e n t o f f o r c e , f r a u d , d e c e i t , d u re s s ,- c o e rc io n .> o r undue
in f lu e n c e .
- - I u n d e r s ta n d t h a t I may w ith d ra w c o n s e n t t o p a r t i c ip a t e i n
t h i s m e d ic a l r e s e a r c h p r o je c t a t a n y t im e , an d may th e re u p o n
d is c o n tin u e p a r t i c i p a t i o n i n th e p r o j e c t , a l l w ith o u t any"
p r e ju d i c e to my c o n tin u e d c a r e a t O r th o p a e d ic H o s p it a l.' '
— I u n d e r s ta n d and a g r e e .th a t a l l d a ta v/hat so e v e r fro m t h i s ’ p r o Â
j e c t may b e p u b lis h e d o r p r e s e n te d f o r s c i e n t i f i c p u rp o s e s ,
o n t h e u n d e r s ta n d in g t h a t my p a r t i c i p a n t i d e n t i t y w i l l n o t % e
d is c lo s e d w it h o u t my p r i o r - w r itte n c o n s e n t. : " - " ' â–
- - I u n d e r s ta n d t h a t I w i l l n o t in c u r a n y a d d i t i o n a l h o s p it a l o r
. la b o r a t o r y e xp en se b y p a r t i c i p a t i o n i n t h i s m e d ic a l r e s e a r c h
p r o j e c t , n o r w i l l I r e c e iv e a n y c o m p e n s a tio n f o r p a r t i c i p a t i o n
i n . t h e p r o j e c t . - , . * â–
- - I u n d e r s ta n d t h a t I w i l l r e c e iv e a co p y o f t h i s c o n s en t fo rm
w h ic h w i l l show a l l s ig n a t u r e s and d a te s .
— I a c k n o w le d g e t h a t 1 am, f l u e n t i n th e ' ' language,
b e in g th e la n g u a g e o f t h i s c o n s e n t fo rm a n d o f a l l v e r b a l
e x p la n a t io n o f th e m e d ic a l r e s e a r c h p r o j e c t . ,
— I a g r e e t h a t I h av e r e a d and f u l l y u n d e rs ta n d t h i s c o n s en t fo rm ,
t h a t I a g r e e w i t h e ac h o f th e a b o v e - lis t e d s ta te m e n ts , and t h a t '
I h a v e r e c e iv e d a c le a r v e r b a l e x p la n a tio n o f a l l a s p e c ts o f
th e m e d ic a l r e s e a r c h p r o je c t s e t f o r t h i n t h i s w r i t t e n c o n s e n t
fo rm .
- - I HEREBY G IVE M Y CONSEI'TT TO PARTICIPATIO N I N THE ABOVE
• DESCRIBED MEDICAL RESEARCH PROJECT.
103
INFORMED CONSENT FOR}! : MEDICAL RESEARCH PROJECT
(ADULT PARTICIPANTS)
D a te d ; 19
S ig n a tu r e o f a d u lt p a r t ic i p a n t
P r in t e d name u i a d u lt p a r t i c i p a n t
____________ -D ated : 19
S ig n a tu r e o f a d u lt p a r t i c i p a n t 's
c o n s e r v a to r o r g u a r d ia n , i f a p p lic a b le : -
P r in t e d name o f c o n s e rv a to r o r g u a rd ia n
C-IINOR PARTICIPANTS)
D a te d : ____________ 19
S ig n a tu r e o r m in o r p a r t i c i p a n t 's p a r e n t , . _
g u a r d ia n o r o t h e r l e g a l r e p r e s e n t a t iv e
P r in t e d name o r p a r e n t , g u a rd .ia n o r . ' ^ '
o th e r l e g a l r e p r e s e n t a t iv e
P r in t e d name o f m in o r p a r t ic i p a n t in
--------- . t h e m e d ic a l r e s e a r c h p r o je c t
(wiT:g:ss)
I c e r t i f y t h a t I h a v e r e v ie w e d te e c o m p le te c o n te n ts o r t h i s c o n s e n t
fo r m w it h t h e p e r s o n (s ) s ig n in g above w ho, i n n y o p in io n , u n d e rs to o d
th e e x p la n a t io n . Any s i g n i f i c a n t change in th e n a t u r e o f th e m e d ic a l
r e s e a r c h p r o j e c t (fro m t h a t d e s c r ib e d ab o ve) w i l l b e f u l l y explained
t o t h e p e r s o n (s ) s ig n in g a b o v e .
D a te d : ____________ 19
S ig n a tu r e o f w itn e s s t o th e p a r t i c i p a n t
c o n s e n t s ig n a t u r e
P r in t e d name o f w itn e s s
104
APPENDIX E
Motor-Free Visual Perception Test
Scoring Sheet
105
Motor-Free visual
Scoring
Perception Test
Sheet
Example A B C D Example A B C D
Item 1 A B C D Item 22 A B C D
2 A B C D 23 A B c D
3 A B c D 24 A B c D
4 A B c D 25 A B c D
5 A B c D 26 A B c D
6 A B c D 27 A B c D
7 A B c D 28 A B c D
8 A B c D 29 A B c D
30 A B c D
31 A B c D
32 A B c D
Example A B c D
Example A B c D
Item 9 A B c D
10 A B c D
11 A B c - D 33 A B c D
12 A B c D 34 A B c D
13 A B c D 35 A B c D
36 A B c D
Example A B c D
Item 14 A B c D
15 A B c D
16 A B c D
17 A B c D
18 A B c D
19 A B c D
20 A B c D
21 A B c D
106
APPENDIX F
Raw Scores and Perceptual Quotients
of Each Subject
107
Raw Scores and Perceptual Quotients
of Each Subject
Sub] .
#
Age
Yrs Mos
Hydrocephalus
(he) shunt? Raw Score
Perceptual
quotient
1 8 6 no he 29/36 100
2 7 3 he with shunt 23/36 92
3 7 0 he with shunt 27/36 105
4 6 9 no he 28/36 112
5 8 0 no he 31/36 111
6 7 11 he with shunt 23/36 90
7 7 3 he with shunt 33/36 124
8 8 8 he, no shunt 29/36 100
9 5 11 he with shunt 11/36 78
10 8 1 he with shunt 26/36 95
11 8 3 he with shunt 25/36 92
12 8 5 he with shunt 27-36 98
13 8 4 he with shunt 27/36 98
14 7 4 no he 30/36 114
15 7 5 he with shunt 22/36 89
16 7 0 he with shunt 15/36 66
17 5 9 no he 24/36 110
18 7 8 he with shunt 30/36 112
19 6 4 no he 26/36 107
20 6 1 he with shunt 16/36 83
21 7 8 he, no shunt 29/36 100
22 7 10 no he 25/36 96
23 7 6 no he 29/36 116
108
Abstract (if available)
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Supowitz, Janet
(author)
Core Title
Visual perception in children 6 to 8 years old with a diagnosis of spina bifida including a group who have hydrocephalus as well
Degree
Master of Arts
Publisher
University of Southern California
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