Running head: EVIDENCE BASED PAPER 1

OCCT 526: Evidence Based Paper

Touro University Nevada
Justin Christman and Tiffany Poon

EVIDENCE BASED PAPER 2
Research Question

How prevalent is visual-perceptual impairment in the population of children with cerebral
palsy, specifically, which subtype of cerebral palsy has more frequency of visual-perceptual
impairment?
ABA Reference
Stiers, P., Coene, S., DeRammelaere, M., Vandenbussche, E., Vanderkelen, R., & Vanneste, G.
(2002). Visual-perceptual impairment in a random sample of children with cerebral palsy.
Developmental Medicine & Child Neurology, 44: 370-382.
How does this study related to your research question?
In this present study, the researchers aimed to determine how widespread visual-
perceptual impairment is in children with cerebral palsy (CP) by evaluating perceptual ability
together with the performance level on non-verbal intelligence subtests. This study also included
a wide range of participants of children with disabilities and other subtypes of CP.
What is the purpose of the study?
Ophthalmologic disorders and poor vision are frequent in children with congenital
physical disabilities and also with children with CP. Although there have been many studies that
were undertaken to substantiate this claim, there were considerable inconsistencies among these
studies. Also, other studies revealed a distinction between visual-perceptual and visuomotor
impairments and suggested that both types of impairments are associated with spastic rather than
Athetoid CP. Most studies took into account the frequent intellectual impairment of children with
congenital brain damage by evaluating perceptual performance against Global or Verbal IQS, but
EVIDENCE BASED PAPER 3
most likely overestimated visual-perceptual problems because often children with CP obtain
lower non-verbal than verbal intelligence scores. Thus, it may be that the frequency estimates of
visual-perceptual problems reflect the prevalence of selective non-verbal intelligence
impairment, in addition to impaired visual perception (Stiers, et al., 2002).
The purpose of the study, however, is to obtain a more accurate estimate of the
prevalence of visual-perceptual impairment among children with physical disabilities more
specifically (1) the frequency of visual-perceptual impairment in children with spastic diplegia
and either it is also apparent in other types of CP; (2) whether visual-perceptual impairment is
typical for diplegia and whether it is also apparent in other types of CP and (3) if visual
perceptual impairment also occurs in children with physical disabilities due to causes other than
perinatal hypoxic-ischemic brain damage (Stiers, et al., 2002).
What are the research questions/hypotheses?
The research hypotheses states that the visual-perceptual impairments are prevalent in
children with physical disabilities, particularly in those with CP and this study will yield
different results than previously because it will take into account the selective impairment of
non-verbal intelligence that is frequent in these children.
Does the literature review justify the need for this study?
Yes. The literature review stated that although there has been substantiate studies to claim
that visual impairment is persistent in children with CP. But the need for this study is justified
because the present study states that there have been considerable inconsistences with previous
studies.
EVIDENCE BASED PAPER 4
What is the study design/type of study? What is the level of evidence?
This study is a quantitative study with a random sample.
How many participants? How were the participants recruited and selected? How are the
participants described?
In this study, there were a total of 96 participants; 44 females and 52 males. The
participants were selected from an institute for children with physical disabilities in the
Dominiek Savio Institute in Gits, Belgium. The participants ages ranged from 4 years 11 months
to 21 years 5 months. These children had a non-verbal mental age between 3 and 7 years with a
Total IQ greater than 85 in 91% of the participants. In addition to the children with physical
disability, the study also included the results of 21 typically developing children; 9 females and
12 males with ages ranging from 4 years 3 months to 4 years 8 months.
If applicable, how were participants assigned to groups?
The largest group of participants comprised of 68 children with CP due to prenatal,
perinatal, or neonatal hypoxic-ischemic episodes; this group is labeled the CP group. Spasticity
was the predominant type of motor impairment, but three children had dyskinesia and one had
ataxic CP. Five children had motor impairment due to brain damage; this group is labeled the
acquired group. The third major category comprised of 10 children with motor impairment due
to neural malformation; labeled the neural malformation group. Four children had spina bifida,
six children had neural abnormality restricted to the brain, one child had caudal regression
syndrome with no involvement of the brain and one child had Arthrogryposis Multiplex
Congenital. This group is labeled the peripheral disorder. The remaining eleven children were
combined in the miscellaneous group, which consisted of children with psychomotor
EVIDENCE BASED PAPER 5
impairments with unknown etiology to non-spastic motor impairment in the lower limbs with
Moebius syndrome and pituitary hypogonadism. Lastly, the group of typically developing
children is labeled the non-disabled group.
What are the variables? Independent and dependent if applicable.
There were no variables used in this study.
What measures were used?
Visual acuity was assessed with the GARA using square-wave gratings in a two
alternative forced-choice staircase procedure. The L94 comprises of eight visual-perceptual tasks
designed to assess visual-perceptual abilities at the preschool level in children with multiple
disabilities. The first task, Visual Matching, comprises 10 items presented on a computer in
which a target drawing is presented and then replaced by four alternatives. This task probes the
ability for semantic categorization of common objects. The next four tasks look for disorders of
perceptual categorization. The last three tasks are pen and paper tasks assessing visual-
constructional abilities. Multiple tests were used to estimate the performance ages of the
children: WISC-R, WPPSI, Snijders-Oomen Non-verbal Intelligence Scale, the McCarthy Scales
of Childrens Abilities and the Revised Amsterdam Childrens Intelligence Test (Stiers, et al.,
2002).
If applicable, what is the intervention?
There was no intervention applied in this study.


EVIDENCE BASED PAPER 6
What statistical analysis was used?
Significance of parametric statistics was established through randomization tests. This
avoids the assumptions of normal distribution and homogeneity of variances of the data, which
underlie traditional parametric tests and the transformation to rank scores underlying traditional
nonparametric tests. Reported p values are based on 10,000 redistributions of the data set, or on
all possible permutations where this was feasible, in which case the exact probability is reported
(Stiers, et al., 2002). Correlations involving one or two dichotomous variables were expressed,
which are the approximations of the product-moment correlation. Reported p values are one-
tailed, except for ANOVA F tests, and significance was set at p < 0.05. (Stiers, et al., 2002).
What are the findings?
Of the 68 children with CP that followed perinatal and neonatal complications, 39.7%
showed evidence of visual-perceptual impairment. The average number of L94 tasks on which
these children with visual0perceptual impairment scored below the 5
th
percentile was 1.89. Only
the hemiplegia, diplegia, and quadriplegia subgroups showed significantly more L94 impairment
per child than the non-disabled control group. There was no significant difference for the mixed
group and the dyskinetic-ataxic group. The one child with ataxia included in the latter group was
not impaired on the L94. There was also no significant difference among the CP subtypes. Also
in the CP group, about half of the children with diplegia and quadriplegia had reduced acuity,
while visual acuity was better in children with hemiplegia. One child with mixed type of CP and
all children with non-spastic CP had normal acuity (Stiers, et al., 2002).
It was also found that visual-perceptual impairment was not confined to children with
CP; the study shows a distribution of L94 impairment in four main classes of physical
EVIDENCE BASED PAPER 7
disabilities. Compared with the non-disabled group, the mean number of impaired L94 tasks per
child was significantly higher in the acquired group, the malformation group, and the peripheral
disorder group. One finding concluded that the group with brain malformation showed the
highest incidence and severity of L94 impairment of the entire sample. Another finding
concluded that visual acuity reduction was also most frequent in children with neural
malformation and also high in the miscellaneous group (Stiers, et al., 2002).
Lastly, this study also investigated the effect of having a history of seizures and
prematurity at birth. It was found that there was no significant relationship between the presence
of epilepsy and reduction grating acuity, impairment on separate L94 tasks or between the
numbers of L94 impairments per child. For the nine children born before the 28
th
week of
gestation, only 11.1% were impaired on the L94, compared with 42.7% of 25 children born
between 28 to 36 weeks of gestation, and 40.8% of 49 children born at term. The average
number of impaired L94 tasks per child was lower in the severe preterm group than in the mild
preterm and the term group, although it was not significant ((Stiers, et al., 2002).
Do these findings support the hypothesis?
Yes. These findings support the hypothesis that children diagnosed with CP have greater
visual impairment compared to non-disabled children as well as children with other disabilities.
How do the findings relate to previous research as described in the literature review?
The findings relate to previous research stating that children with physical disabilities,
especially CP, have a high prevalence of visual-perceptual impairment. These findings also
report that it is not only children with CP who experience visual-perceptual impairment. Because
this study includes children with other physical disabilities such as brain malformation, it also
EVIDENCE BASED PAPER 8
relates to previous research about visual-perceptual impairments in 55 to 60% of children born
prematurely and in up to 70% of children with hydrocephalus and spina bifida.
Does the author state any clinical implication for the findings?
Yes, they indicate that the reduction in visual acuity and specific visual-perceptual
impairments are frequent in children with CP and in children with early brain damage in general.
What are the limitations that the author identifies?
Some of the task scores could not be evaluated because the tasks were too difficult for some
children under 5. Another indicated limitation reveals some children could not comprehend the
test being administered, and other childrens fine motor skills were not sufficient to complete the
pencil task.
Does the author discuss implications for future research?
Yes, the author states that the exact nature and the impact of impairments studied are not well
understood at this time and require further research.
What would you say about the sample size? Do you believe it is adequate?
The sample size was large (n=96-disabled) and (n=21-non disabled). We believe that this
sample size for this particular study was adequate enough to have reliability on the findings.


EVIDENCE BASED PAPER 9
If the researcher did not find a significant difference between the groups, is it possible that
this is due to a type ll error? If so, why do you think so?
We believe this is possible. Of the eight tests used, four provided measureable data. These
four tests made use of the object recognition paradigm; however its not shown if the deficit is in
object recognition. The tests used did not completely measure what they were intended to
measure indicating a Type ll error.
Is there a control comparison group? If so, is the control or comparison group comparable
to the experimental group on key features?
Yes, the control comparison group consisted of 21 non-disabled children ranging from 4
years 3 months to 4 years 8 months. Four of the eight tests administered (GARA, Visual-
perceptual battery L94, VISM, and WISC-R) did not show any difference between physically
disabled children and typically developing children.
Are those administering the outcomes measure blind to group assignment?
No, they strategically assigned children with specific diagnoses into five individual
categories: CP group, Acquired group, Neural Malformation group, Peripheral Disorder, and the
Miscellaneous group.
Are the participants blind to the group assignment?
The article does not specify if the children were blind to their group assignments.

EVIDENCE BASED PAPER 10
Does the researcher account for drop-outs in the study? Could drop outs have influenced
the outcome?
It is not specified if drop-outs were accounted for. We do not believe drop outs could have
had an impact on the outcome of the study.
Does the researcher report reliability and validity of the outcome measures? Are there
questions out the outcome measures chosen?
The article does not directly indicate the reliability or validity of the outcome measures. We
do not believe this test is reliable due to the confusing nature of the article. Lack of validity is
shown by the fact half of the test used did not measure what was set to be measured.
What confounding factors could contribute to or influence the study outcomes?
Confounding factors may be related to the fact half of the test administered were deemed
inconclusive.
What are the major strengths of this study?
(1) One major strength about this study is the large sample size of children with physical
disabilities and also having a control group of non-disabled children
(2) Another major strength of this study is how many visual tests the researchers applied to
each child; varied from visual acuity to visual-perceptual batter (L94) which had a total
of eight tasks for each child to complete.
(3) The final major strength was the indication to the development of further research
regarding children with cerebral palsy and visual-perception deficits.

EVIDENCE BASED PAPER 11
What are the major weaknesses of the study?
(1) Although this research study states that primary focus on the research is the prevalence of
visual-impairment is in children with CP, the researches included many other subjects
that were not diagnosed with cerebral palsy. This brought confusion throughout the entire
article and the findings even more difficult to understand. If this study were to focus on
just the population of children with cerebral palsy and the control group, the study may
have resulted in more significant findings
(2) Another weakness we found in this study is the lack of information about previous
studies. This research arose because of inconsistences of other visual-perceptual studies
in children with CP, but it did not clarify what led to the inconsistencies in previous
studies to make this current study more reliable. We believe it would have been very
beneficial for the reader to know what specific inconsistences there were in previous
studies.
(3) The last weakness is involves the children in the control group. Although these children
are described as typically developing, the parents reported neonatal and neurological
perinatal complications. Researchers neglected to reveal what specific complications
these children were exposed to in comparison to those children with CP and related
diagnoses.
How would you use this article as a therapist?
Because this article did not provide an actual intervention study, this article has limited
use to a therapist. It does, however, confirm to all therapists that children born with physical
disabilities from CP to neural malformation and preterm babies are all at high risk for visual
EVIDENCE BASED PAPER 12
impairments and most likely visual-perceptual impairments. Knowing this, therapists should be
aware when working with pre-mature babies and young children with physical deficits may
possibly have visual impairments. This should guide the therapists intervention appropriately to
the childs visual impairments because the link between the environment, brain, and the eyes is
the most important connection to promote physical, social, and emotional skills.
How does this article support/not support participation in occupation and the field of
occupational therapy?
As human beings, vision is a key piece to our success regarding every day activities.
Without adequate vision and perceptual skills everyday life could become extremely difficult.
Depending on a practitioners specific setting, articles such as this could be a very useful
resource. It could give an indication on the severity of an individuals condition related to their
visual-perceptual skills. Other related articles could give rise to appropriate modalities and
therapeutic interventions to be implemented towards individuals with disabilities as those
discussed in this article.