DEVELOPMENTAL PERCEPTUAL-MoTOR DISORDERS

DEVELOPMENTAL PERCEPTUAL-MOTOR DISORDERS l

YVONNE BURNS, DIP.PHTY.

AND

PAULINE WATTER, B.PHTY.

Queensland Spastic Welfare League, Brisbane.

85

THE PROBLEM

To understand or even begin to conceivethe problems of the perceptually-motor han­dicapped is an enormous task. We have de­veloped our personalities and abilities in astable and meaningful environment and oursecurity lies in our ability to manipulate ~ndgive meaning to this environment. ~mag~ethe difficulties that are faced by la child wIthperceptual-motor problems. By this, we meanthat he has problems with:

(I) inaccurate or distorted input in thefields of vision, audition, propriocep­tion, kineasthesia and tactility,

(2) inaccurate integration of this input,(3) inaccurate motor output or inadequate

responses.

A child with such problems may not beable to find one particular object in a pileof toys, or he may not respond to his ownname if there is noise around him. For somereason, he cannot select the correct objectfor attention-he cannot discriminate accu­rately between the figure or important featureand the ground against which it occurs. Withproblems in another area, he may know theparts of his body hut be unable to climbunder a table without bumping himself andif he hides behind a large box, may leavehis legs sticking~out because he is not lookingat them. Again, he may not be able to main­tain eye contact with an object, or find hisway in a familiar environment. He may beillogically frightened by heights or movement.Obviously such a child will have tremendousdifficulties in the school or playground situa­tion, and the problems, if left alone, tend toperpetuate themselves.

:1 Received July, 1971

An object seen on Monday may appeardifferent from the same object seen on Tues­day, because of some trick of lighting orchange in angle of view. For the normalperson, perceptual constancy (which is afunction arising within the brain) allows usto overcome such differences in perceptions,and maintains the stability of our perceptualenvironment. However, for those with per­ceptual-motor problems, the increasing. am­biguity and confusion of perceptual Inputprovokes a variety of responses and a varietyof feedback in the one learning situation.This alone renders adaptation and learning aformidable task, especially as these childrentend to have problems in several areas ofperceptual functioning.

In normal perception, there is a superfluityof information giving reinforcement and con­firmation from all senses. With disturbanceof the normal, there is often conflict of in­formation from different senses, producingconfusion and indecision as to identity,orientation and direction. Current theoristspresume the disorder to be labile, and havedeveloped various remedial approaches basedon their individual theoretical ground. Theyare concerned mainly with building up per­ceptual motor skills that have shown as de­pressed on tests used. In this paper, theauthors present the problems which may arisein relation to physiotherapy and the conse­quent implications for therapy.

CURRENT ApPROACHES TO PERCEPTUALMOTOR FUNCTIONING

Kephart and Roach (1966) have offered acomprehensive perceptual motor theory oflearning which is better described as a visuo..motor theory. For Kephart all behaviour isbasically motor, and perception has no mean-

Aust. J. Physiother., XVII, 3, September, 1971.

86 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

ing until matched wth a motor pattern.Movement patterns and postural adjustmentsare postulated as the bases for the develop..ment of body image, which in turn, is pre­requisite for the development of the conceptsof laterality and direction. By manipulatinghimself and objects in relation to himself, thedeveloping child perfects the matching ofsensory and motor data. The proposedmechanism by which this occurs is a servo..mechanism-a closed system with a feedbackcontrol provided by sensations arising fromthe movement. Thus the child learns generalmodes of responding which Kephart describesas flexible, adaptive and selective.

Direction and laterality are developedthrough matching visual and kinaestheticclues. The concept of space can therefore beextended beyond the body, and direction andposition given to external objects with respectto the child's position. Throughout his theory,Kephart seems to attach decreasing impor..tance to senses other than vision, and so histheory eventuates as a visual-motor and nota perceptual-motor one. He claims thatadequate motor output relies upon the ade..quacy of the integrative pattern that directsthe output, and also upon the accuracy ofthe feedback (Calder 1970). If either ofthese is inadequate, then the development ofnormal movement patterns must be affected..It must be remembered that the factors whichcause damage to the perceptual-motor sys..terns are also able to affect the systems con..trolling motor activity. Hence the motorequipment may be affected by other thanperceptual-motor deficit and this may pre­determine the nature of the movement patternsthat are present and that are capable of de­veloping. The physical limitations imposedby such other motor handicaps may furtherimpede the development of correct associa­tions between sensations and motor activity.

Cratty (1967) is initially similar in hisideas to Kephart. His particular value, how­ever, is that he has developed a completeand logical remedial programme based onthe development of task sequences. He givesexpected performances for various groupssuch as mongol, subnormal and cerebralpalsied children. The task sequences are

Aust.l. Physiother., XVII, 3, September, 1971.

physically orientated and rely largely onvisual..motor performance. It emphasises totalbody involvement and accuracy of movementas it progresses from tests of body image,through balance and locomotion, to strengthand agility.

Denhoff (1968) also is similar to Kephartin his basic ideas. He claims that posture,sense of direction, laterality and awarenessof body position in space are the motor basesof perceptual development. He has shownthat if complete sensory or motor deprivationoccurs, normal behaviour is delayed and dis ..torted. What, therefore, is the effect of partialdeprivation, by virtue of faulty sensory in­formation and inadequate motor responses, onnormal behaviour and development? Correctfeedback is essential for perceptual learningand Denhoff has shown how the inaccuratedevelopment of the perception of depth leadsto persisting fear of heights. He devised anearly remedial programme based on:

(1) Development of body image using allareas of sensation to increase aware­ness.

(2) Development of eye..hand co-ordina..tion.

Brereton in conjunction with JenniferSattler (1967) has developed a remedial pro­gramme for children with perceptual..motorproblems. The programme requires an in­tellectual level of about 31 years to beginwith, and aims at introducing the child toand improving his "Basic Abilities". Thetheoretical bases of the programme involvefirstly, the recognition of the importance ofthe linking of information from varioussenses, secondly, the concept that inadequateexperience can affect learning (thereforemodification is possible by affecting the ex...perience available) and finally, the acceptanceof a sequence in development of sensory andsensory-motor function. Like Kephart (1966)and Ayres (1966) Brereton emphasises theinitial importance of tactile sensations in thedevelopment of body awareness (comparealso with Abercrombie, 1964). Later kin..aesthetic clues are important, but visual clueseventually become most important His pro­gramme places more importance on presentingthe various sensations and sensory intercon..

DEVELOPMENTAL PERCEPTUAL-MOTOR DISORDERS 87

nections, whereas Kephart's is more orientatedto exercise and physical experience. Testingon the Illinois Test of PsycholinguisticAbilities by psychologists and on Ayres testsby occupational therapists, the presence ofperceptual-motor problems are established.Every child suitable for the programme be­gins at the first section and works through.Check tests are used after each section iscompleted and rate of working varies witheach individual and his particular problems.This programme has been instigated at theQueensland Spastic Centre where it is con­trolled by the Occupational Therapy Depart­ment. Thomas (1966) has developed an ap'"proach to the development of perceptual andmotor skills in the infant. He regards move­ment in the child as existing on a continuum,beginning from early in the life of the foetus.He explains how the initial stimulation of thefoetus is tactile in origin, coming from theutrine walls and pressure through the mother'sabdomen, and from contact with his ownbody parts. Reflex movements occur in res­ponse to these stimuli, and the beginnings ofmovement patterns are laid down. As thereflex movement occurs, proprioceptive im..pulses and exteroceptive stimuli are producedand so the patterns continue to build up..For Thomas then, movement does not appearsuddenly at birth, behaviour patterns havealready begun to he established by this timeand they are adaptive patterns. If the neuro-­logical equivalents of movement patterns havenot been established before birth, it wouldbe impossible to elicit the reflex walking andstepping which Thomas has demonstrated inthe first hours and days of neonatal life. Thenewborn has been shown to he capable ofadaptive behaviour, such as stepping overobstacles, and learning a head-turning res·ponse to his mother's call by one month ofage.

Factors interfering with normal develop­ment before or at birth or in the earlymonths of life, would naturally affect dras..tically the nature of perception, of integrationand of reflex motor behaviour, consequentlyaffecting the normal behaviour patterns whichshould have been established and consolidatedat that time. Thomas places much importanceon the contribution of all the senses. He

emphasises how these are normally linkedup and integrated continually and how thestimulation received from the senses plays alarge part in the functional development ofthe nerve centres.

His approach is supported by the works ofAbercrombie (1964) and Vernon (1968).Abercrombie stresses that there are two typesof problem associated with perception. Firstly,there is one of inaccuracy of perceptual inputand its integration, and secondly there is oneof integration and motor inaccuracy. Hefeels that people with a perceptual-motorhandicap can usually perceive differenceseven if they cannot replicate the form. How­ever, they may tend to see (perceive visually)in a more primitive way; that is, they mayperceive at the global level, seeing a wholemass with no parts, or they may see the partsof an object separated spatially. As a resultof having a visuo-motor disorder, the am­biguity and the confusion of sensory inputmay yield a variety of feedback in one situa­tion. If the feedback is constant, althoughinadequate, some adaptation may he possible.However, if the information changes withoutpattern, no adjustment can be made, andfrustration as well as inadequacy may result.Reinforcing this, Vernon shows how integra..tion breaks down if unusual or conflictingstimuli are received from different senses,hut if the conflict is constant, modificationof the input occurs and adaptation to recreatea stable worfd is possible..

OBSERVABLE MANIFESTATIONS OF PERCEPTUAL..MOTOR PROBLEMS IN CHILDREN

Observable manifestations of perceptual..motor problems are:

1. Abnormal fear of heights, large objectsand/or moving surfaces.

2.. Hyperactive behaviour, both physicaland verbaL

3. Withdrawal from people and/or stimu­lation (hypo..activity).

4. Disorganized play or body movements.

5. Short attention span and consequent dis..tractability.

Aust. J. Physiother.,. XVII, 3, Septemberj 1971.

88 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

6. Inability to change position, routine orvisual focus.

7. Clumsy and awkward body management.8. Poor balance.9.. Poor posture.

10. Apraxia of movement (unable to do atask within his physical capabilities).

II. Persistence of associated reactions.12,. Left-right confusion.13. Lack of body position awareness.14. Lack of sense of direction.15. Inability to go economically from one

position to another.16. Inability to cross the midline---visually

or physically.17. Inability to copy patterns of movement,

sound or vision.18. Lack of reciprocal movement.19. Ignoring body parts.20. Reliance on particular sensory inputs.21. Poor righting reactions.22. Poor visual control and eye follow.

Areas of Problem as Related toObservable Behaviour

It is essential not to forget that, despitehis problems, the child with perceptual-motorproblems is often of normal or above normalintelligence. If a child's concept of his ownhody (body image) is disturbed it can oftenbe demonstrated by the Goodenough "Drawa Man" test. If he is unaware of the relation­ship between his own body parts, or of howlnuch space he occupies, then movementthrough an environment peopled with objectsbecomes hazardous. If he does not knowhow much room his own body needs, he hasno standard by which to judge the size ofanything else around him or how much spaceit requires. For such normal and basic judg­ments, he must accurately know where he andhis body parts are and also know where otherobjects are in relation to him. Later, he willbe able to judge the relationship betweenobjects without having to refer to his ownposition. Problems in body image and spatialconcepts are frequently relatedo A functional

Aust. J. Physiother., XVII, 3, September, 1971.

knowledge of and dealings with, personalspace are prerequisite for the concept of ob­jective space" The production of an adequatebody image must rely on a build-up of accu­rate sensory information from all areas.

If a child has figure-ground problems, itis likely that an observer will detect an in­ability to select the significant factor from thebackground, or an inability to impose formand meaning upon the sensory input. Thisconfusion may be more readily seen in thevisual and auditory fields-in selecting theessential words from a sentence so that acommand may he carried out, or selecting theimportant object in a picture. This sort ofbehaviour must also be considered in relationto hyperactivity and short span of attention.The child appears unable to maintain con­centration on one thing and attention wandersto the irrelevant. This child is perpetuallyactive and highly aroused, being unable toselect the essential from all the stimuli im­pinging on his sensory systems. Play maybe disorganized as the child switches fromone activity to another, and this is a differenttype of disorganization from that producedby disturbed body image.

If kinaesthetic and proprioceptive sensa­tions are distorted, then fear of basic move­ment from one position to another or of anymovement may result. Later this may be seenas a fear of climbing. If asked to hide, thechild may not conceal his legs because, whenhe does not watch them, he receives inade..quate information as to where they are. Hemay be unable to judge how much movementwill make his arm move a specified distance,or may not he able to judge the effort re­quired. It could also be difficult for him todifferentiate between the feelings of left andright side of the body. Kinaesthetic andproprioceptive inaccuracies can cause clumsi­ness and poor balance, and are closely relatedto problems of body awareness.

The importance of visual perception is em­phasised usually because vision is acceptedas the dominant sense. There are two mainareas in which problems arise. The figure­ground problem may he only in the visualarea, or problems may arise from abnor­malities of ocular control (lack of eye follow,

DEVELOPMENTAL PERCEPTUAL..MoTOR DISORDERS 89

nystagmus, squint). However, when visual in­formation is inaccurate, this will affect thereliance of the individual upon it. If a childcannot maintain visual fixation when andwhere he desires, or cannot find an objectquickly once his gaze wanders, he wastestime by having to scan the field for the objector to find points for visual orientation. Ifin this field, as in others, a child is forced todirect his consciousness to maintain suchfunctions as are normally automatic, he hastittle energy or attention left to cope withremaining tasks. Lack of eye follow or con­tinued contact, may also he related to hyper­activity and short attention span. Visual prob­lems may therefore account for some apparentclumsiness, such as bumping into things, andapparent spatial problems.

Motor planning is related to sensory input,and integration involves the ability to planappropriate movements or responses. A childcan appear clumsy and unable to perfonnmovements which he is physically capable ofperforming. He may "take the long wayround" as a result of being unable to planeconomical movement. The child may appearapraxic for fine movements (simple dressingactivities) or have poor posture and balance.Even though he knows which direction hemust move in to intercept a ball, he cannotmake his legs move him accordingly. It isobvious then, in observing behaviour of thechild that several areas of problem may beaffecting a particular behaviour. One mustthen look at all behaviours to determine thecontribution to the problem by different areasof dysfunction.

EVIDENCE TO SUPPORT PARTICULAR SIGNS OFPERCEPTUAL-MoTOR PROBLEMS

Squint and Movements of the Eyes

Many children with minimal cerebral dys­function suffer from squint and 56% ofovertly cerebral palsied children also sufferfrom squint (Denhoff and Robinault, 1960).A high percentage of cerebral palsied childrenand children with minimum cerebral dysfunc­tion also have perceptual motor problems.There would seem to be a connection betweenthe presence of squint and the presence ofperceptualwmotor problems. Benton (Aber-

crombie, 1964) has shown how squint ad­versely affects achievement on performancesubtests of the Wechsler Adult IntelligenceScale and depresses their intelligence quotaaccordingly. Squint produces double vision,therefore, to cope with the environment, thediscrepant information from the convergenteye is suppressed to the point where vision inthis eye is lost (Denhoff and Robinault,1960) .

The perception of depth arises from thekinaesthetic impulses from the ocular musclesand from perceptual clues observed such asgradient of texture, interposition of objects,shadows and clarity of outline. In the normalchild with squint, although the kinaestheticimpulses from the ocular muscles may be dis­torted or lost due to incorrect position of theeye and although there will be consequentdisturbance to retinal image disparity, therestill remains many accurate clues to depthperception and such perception will not neces..sarily suffer. Also, concepts of spatial rela w

tionships are similarly reinforced by sensa­tions from other areas, and, therefore, maynot suffer (Abercrombie, 1964). However, inthe child with perceptualwmotor problems,these other clues to depth perception may alsobe incorrectly perceived or interpreted, andthis will have a much greater effect on theirperception of depth. It is easy to see then,how apparently irrational fears, such as thoseof high places, can arise in children withinadequate perception of depth by virtue ofinadequate input, processing or output. Per..ception of depth is related to judging heightsof objects, distance between stepping stones,or distance to jump down from a kerb. In­ability to function well on such tasks mustperpetually place the perceptually-motor han­dicapped at risk in our world.

Excessive or uncontrolled ocular move­ments cause incorrect kinaesthetic impulsesfrom the ocular muscles to be sent to thebrain and can result in disruption of thesequence of visual images (Abercrombie,1964) . In addition, an inability to trackobjects and to maintain visual contact mustaffect the child\) ability to organize his en­vironment. This has also to be consideredin relation to hyperactive behaviour and short

Aust. J. Physiother., XVII, 3, September; 1971.

90 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

attention span. Thus, if a child does sufferfrom perceptual-motor problems, then thepresence of squint or lack of eye follow, orthe presence of apparent blind spots, are alllikely to contribute greatly to his problems.

Righting ReactionsRighting reactions develop in the normal

child between six weeks and six to sevenmonths of age~ Lack of these reactions be­yond this period may be an indication thatproblems exist for that child. Righting re­actions are the initial responses of the infantin adjusting his body to the force of gravity.Initially, labyrinthine, then optical, rightingof the head develops; then head on body,body on head, and body on body rightingappear (Bohath, 1968). At about six months,concurrent with the righting reactions, morecomplex reactions to gravity begin to appear.Protective extension of the arms in sittingare seen and also, in the prone position,equilibrium reactions to tip.

Working with cerebral palsied children, wefound that by observing their reactions tomovement, to handling and to change of posi­tion, we couId predict for children under twoyears of age, certain perceptual..motor prob­lems. This was substantiated at a later ageby testing on standardized forms. One par­ticular group which always had problemswere those children who had late or faultydevelopment of head and body righting.

In this area, most attention had been drawnto the testing and remediation of visual clues,and visual-motor development. If, however,the visual input or integration is faulty, theresponse must be adversely affected. Theproblem remains unsolved. If we cannot auto­matically adjust our body to gravity andhave some awareness of our position in space,how, then, can we accurately form otherspatial concepts..

ExAMINATION OF SPATIAL CONCEPTS

Stimulated by these problems we set outwith these aims:(I) To examine the recations of the body

to gravity and to itself without vision..(2) To find objective, rather than subjective,

tests for the very young, the non-verbal,the shy or retarded child.

Aust. J" Physiother., XVII, 3, September, 1971.

(3) To discover if particular motor problemswere related to particular learning diffi­culties.

Method

With sight occluded by blackened goggles,we tested three sets of reactions.

1. The reactions of head and body to gravitywith the child minimally supported inprone, supine, on the right side and onthe left side.

2. The reactions of head and body whilesitting on a stool without hands or feettouching support. The stool was tippedforwards, backwards, to the left and tothe right.

3. Lying on the floor (a) reactions of thebody when (i) the head was turned left,~ii) the head was turned right (b) re­actions of head when (i) the left leg wasflexed and rotated to the right, (ii) theright leg was flexed and rotated to theleft.

At all times one person performed the tests,and either one or two observers recorded thereactions~

Population

We tested three groups of children, two ofnormal children and one of children withestablished specific learning difficulties.

Group 1 - School entry class. Nineteenchildren, with similar numbers of boys andgirls, 5 to 6 years old.

Group 3 - Pre-school group. Twenty chilodren, with similar numbers of boys and girls,3i to 5 years old.

Group 3 - Perceptual-motor difficultiesgroup. Eighteen children with learning prob­lems, similar numbers of boys and girls, aged3i to 8 years. Most had neurologicalsymptoms.

ResultsTest 1

Although the numbers used do not permitus to claim that the difference in the responseof head~righting between the normal groups

DEVELOPMENTAL PERCEPTUAL-MoTOR DISORDERS 91

Having investigated all our aims, we notedthat from two essentially normal samples, wewere able to detect several children whom wefelt had perceptual-motor problems. We hadno previous infonnation on the children. Twocases are cited in summary:

the school girls were considerably more maturethan the hoys.. Often, when Tests 1 and 3 wereconsidered together, there were indications ofthe dominance of an individual, which couldbe relevant for learning problems. In thistest, as in all of them, the completeness ofthe reactions, the fear of the position andseeking of other sensory clues as well as therapidity of the reaction, all have to be con­sidered. A reaction which is very quick orextreme can indicate as much difficulty as avery slow or inadequate one, even though theactual problems may differ.

Case 1S., male, age 5 years. Pre-school group.

Tests showed incomplete head reactions; insupine, no reaction at aIL (When he heldon to tester because of fear, he then rightedhis head completely.) He continually movedhis limbs seeking proprioceptive information.Head predominantly turned to right in Tests 1and 2. In Test 3, on head turn, he flexedhis legs (unusual for this age group) andhe failed to right his body in response to legturn.. Later we were told that he walked at22 months, was clumsy and often fell over.There was considerable concern over hisability to cope with the school entry pro­gramme.

Aust. J. Physiother., XVII, 3, September, 1971.

and the perceptual..motor difficulties groupis significant, it would appear that there is adefinite trend in that direction. More exten­sive studies would be necessary to establishmore rigidly the significance of the clifference.Nevertheless, it does appear that there is adefinite relation hetween normal headwright-iug and lack of learning problems, and he­tween the presence of learning problems andabnormal head-righting reactions, as testedhere.

TEST 1

Positive Head Reaction to Gravity (0/0)

Right Left SideProne ISupine Side SupportedSupported

Group 1 90 80 80 80Group 2 90 74 75 75Group 3 45 12 15 12

It is interesting to note that a hoard pressedagainst the feet of those with deviant res­ponses usually increased the incorrect res­ponses, but occasionally correction occurred.

Sex differences also were apparent. Theboys' adjustments were more mature thanthose of the girls, who relied more on visualand proprioceptive clues. Again, largerstudies are required to validate this finding.In Group 3, some children always placed thefloor below their feet and the ceiling abovetheir head, regardless of their orientation inspace. However, some children in all groupswanted more auditory or proprioceptive cluesto build up a feeling of their body positione25% of Group 1 children and 40% of Group2 children rotated their head in the directionof gravity.

Test 2We eliminated this test result because the

children used so many proprioceptive cluesfrom their buttocks and used complex equilib..rium reactions. Minimal results were ob­tained. Results in normal groups were sovaried as to be inconclusive.

Test 3The full significance of these results is not

understood. Again, the girls of Group 2 hadmore immature responses, indicated by morecomplete following of head on body, whereas

(a)

Group 1Group 2Group 3

(b)

Group IGroup 2Gr-oup 3

TEST 3

Positive Body Reactionto Head Turn (%)

505

15

Positive Head Reactionto Leg Turn (%)

607590

92 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

Case 2P., male, age 5! years. School group. He

had incomplete head reactions in Test 1, andin supine, no reaction. On the left side herotated his head with gravity. A board placedunder his feet increased his abnormal res­ponses. In Test 3, his reactions were com­patible with the average for this group.Throughout the tests, his reactions indicatedmixed dominance. Later we were informedthat he was an identical twin, had delayedspeech, learning problems and early mirrorwriting.

ASSESSMENT CHART

Initially, we wondered if we could differen­tiate children with perceptual-motor problemsfrom those who are developing normally byobservation of their performances during acourse of assessment. To do this, we foundit necessary to formulate a series of taskswhich tapped various perceptual..motor areasand to observe how the child reacted to them.By comparing their functioning with a know­ledge of normal level of functioning, it waspossible to determine if the behaviour wasoutside normal limits for that child's age, andfurther, to attempt to analyse in which areasof perceptual-motor functioning the deficitwas occurring.

To simplify the task of assessment, wefound it useful to formulate a card on whichbehaviour can be recorded. There are ninesections, the first three are specific tests notingreaction to gravity and the remaining six arebroader areas of functioning. We hoped thatthis analysis of behaviour would reveal whichareas were at fault. We then compared ourestimates of the problem with standardizedtest (Illinois Test of Psycholinguistic Abilitiesand Ayres Tests) and they correlated fairlywell, but no figures are yet available.

The sections of the card were as follows:1. Head and trunk reactions to gravity

(blindfolded). Test positions suspended(i) prone (ii) supine (iii) right side sup"ported (iv) left side supported.

2. As for I without blindfold.3. Head, trunk and limb reactions to turning

(on floor)(a) head turn to (i ) left (ii ) right;

Aust. J. Physiother., XVII, 3, September, 1971.

(b) (i) left leg flexed to right (ii) rightleg flexed to left.

4. Body position awareness, i.e. being ableto adopt a required position after (i) ver­bal instruction, (ii) demonstration.

S. Body space awareness, e.g. climbingthrough, under, between, behind. Judge­ment of distance. Reaching and placing.Catching balls, etc.

6. Direction relative to space, and what senseis used to find direction, e.g. vision (blind­fold), auditory (sound) or proprioceptive.

7. Development of balance mechanism-useof righting or protective reactions, orequilibrium.

8. Particular fears, e.g. height, large objects,moving surfaces, enclosed spaces.

9. General remarks e.g. clumsiness, disor­ganization, hyperactivity, inahility to per­form movement that physically the sub­ject should he capable of; over-relianceon a particular sense; lack of eye-fallow.

CASE STUDY

S.J., bOlll 11.1.64.Birth History: 5 weeks premature, cyanotic at 65

hours.Milestones: Sat alone, 15 months.

Walked 2~ years.Single words, 15 months.Never crawled.

Presenting Disorder: frequent falls, difficulty indressing, inability to write hut could understand andrecognize letters and numbers.

Initial Physiotherapy Assessment: April 1, 1971.Reassessed: May 14, 1971.Treatment: Half an hour per week for 6 weeks.

Physiotherapy AssessmentS. was a co-operative and friendly child who

seemed to be socially mature for his age. Whensuspended blindfold, his righting reactions wereincomplete or absent, and he clutched at the tester.Only in prone could he orientate himself (this isthe easiest position to do so). With his eyes open,his reactions were very similar, so he was not takingnotice of his visual clues. Despite this, he wasorientated for the whole time. When blindfoldedhis gait was ataxic with a wide base. With visionit was within normal limits. In the tests of headand leg turning, he responded only to stimulationthrough the right side.

He could not copy a demonstrated position, butif he verbalized the required relationship betweenbody parts, he could direct his body into those rela­tionships. He could follow a verbal instruction.Throughout his activities S. continuously verbalized

DEVELOPMENTAL PERCEPTUAL-MoTOR DISORDERS 93

his actions, feelings and comments on his ownsuccess. He seemed to regulate his movements attimes by a verbal feedback control. S. dislikedclimbing. He had difficulty stepping the smallestdistance, and he did not know whether to step "up"or "down", or "how far" to step. He could jumpoff a stool but did not know how far the floor wasfrom him. He could not step over a crack of 1inch between two stools, and seemed immobilizedby fear at times. Even when he could not m-ove hisfeet, he would exhibit stress elsewhere by increasedverbalization, hand clapping, tapping his legs andclicking his fingers. Stress showed more on the rightthan the left side. Intoeing was worse up on astool than on the floor, and finger splaying waspresent. If he had climbed up, the experience ofhow high he climbed to get there made it easierfor him to judge how far he had to jump down.S. could not step over a moving rope and had avery poor sense of timing. He was fair at reachingout and stopping or catching a ball but found itdifficult to direct a throw.

S. was able to localize accurately by sound whenblindfolded, and could also balance on the balanceboard when blindfolded. Again, there were manyextraneous movements, apparently to increase proprio­ceptive input. Vision did not seem to play a largepart for s~ and proprioceptive clues were important.He had some loss in ability to eye follow but itwas not severe. Balance reactions were seen if S.was relaxed, otherwise protective extension pre..dominated. Co-ordination was fair hut S. appearedto he clumsy. He was fearful of new situations andheights but fear disappeared if a rail enclosed thechild, even if he did not touch it. He moved quicklyfrom one thing to the next but could concentratewhen it was required of him. Socially he coveredup well for his inadequacies by his speech.

Implications for PhysiotherapyIt was assumed, as a result of assessment on

physiotherapy charts, that the prQblems lay in thefollowing areas:

1. Spatial.2. Visual motor.3. Motor planning.

Problem areas as assessed by occupational thera-pists on Ayres Tests were:

(1) -Motor planning.(2) Visual Motor.(3) Spatial Relationships and Position in Space.(4) Mot()r Accuracy.

Treatment BasesWith S. no strict plan of treatment was used but

a remedial programme followed areas of difficultybrought to light during the course of his assessment.Generally, it was sufficient to present the situationshe found difficult and to guide him through thesewith as little stress and as much success as possible.His habit of verbalization was most helpful, for itis much easier to guide a child if one knows whathe is thinking. We present here the main areas in

which we worked with S., always realizing thatthere are many ways to achieve the same ends. Wespent relatively short periods on eye~follow training,positions and relationships, while longer periods werespent on climbing, jumping and decreasin~ his fearof high places. There was not, usually, a particularsequence to the work except that we began with ashort session on eye·follow training.

Eye~F ollow TrainingCars, trucks, balls and other interesting objects

were used. S. had to chase the car and not lose it,or watch a ball moving in straight lines, circles,obliques and so on. We moved fairly quickly onto"look and stop the object"-then "look and catch"which brought in other areas where he had problems.We started with a large beach ball of bright colour,with S. following its path, then we rolled it to eachother, changing from one side to the other, bouncedit across the floor or in the air. We aimed toproduce a variety of smooth regular movement tohelp, among other things, S's sense of timing. Theability to change path and direction and act accord.ingly is also necessary for these tasks. We pro~gressed to smaller objects, catching and improvingaccuracy of return. Thus we began with relativelysimple tasks, and gradually introduced new factorsenlarging and huilding on those tasks to approachthe normal complexity of our environment and thetasks it imposes.

Relative PositionsTraining in relative positions was also done in

short sessions, where we went through "under","over", "in", "on", "behind", "up", "down", andso on. We copied positions with objective points ofreference for the limbs (e.g., hand on hip) thenwithout reference points. We also did some rolling,somersaulting and jumping to increase his aware·ness of his body limits.

ClimbingS. had the physical ability to climb and jump so

we started climbing onto fairly low stools andjumping down. There was little stress beoausejumping off in a semiflexed "ready to land" positionwas S's way of handling any such situation andrequired little actual judgement of height. We wentthen to stepping from one stool to another, withstools of similar heights. It was easier if therewas no space gap between stools. After convincingand experiencing success, a child is much happierto attempt more threatening tasks. We startedholding S's hand, decreasing our help as we thoughthis ability improved, always taking care not to raisethe level of stress too high.

By increasing the width of the gap, the heightof the stools from the floor or the clifference inheight between the stools, it was possible continuallyto present different and more difficult tasks. S.found it helpful when we spoke tQ him, for eXlample,"Do we step up or down?" "Is it a little step ora big step; a long way or a little way?" He wouldfeel the length of the stool legs with his hand tofind the higher stool, and sometimes had to feelthe edges of the st<lols with his hand to judge the

Aust~ J.. Physiother., XVII, 3, September, 1971.

94 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

width of the gap or where the limits of his stoolwere. By verbally correlating the information, hebecame able to judge better and more quickly.Gradually we set up la series of stools and chairsof varying heights and shapes, in different arrange­nlents and Vv auld progress through this obstaclecourse.

Other abilities were also used. The trampolinehelped to improve balance and ability to controlthe body at heights and to increase awareness ofbody surfaces. Balance board work, both with andwithout vision, also proved useful. "Find me" games,emphasizing the use of one sense (touch or soundor vision) were also enjoyed and were useful foremphasizing selective awareness~ A maze with andwithout vision was difficult but enjoyable.

Results of TreatmentAfter six weeks, S. was reassessed by occupational

therapists using Ayres Tests and by physiotherapyon the chart discussed earlier. Improvement wasfound in many fields, and the only treatment he washaving outside school was physiotherapy.

In school his progress had been noticed as im M

provement in pre-writing abilities (associated withimproved eyeMfollow, laterality, sense of direction,and so on).

Reassessment in Physiotherapy1. Righting reactions were unchanged but S. showed

less fear and less extraneous movement randclutching.

2. His ability to copy a demonstrated position hadimproved.

3. He could climb and jump accurately, step upand down varying distances, step across a gapand he could estimate distance.In reaching he had better timing and spacingand could jump over a moving rope.

4. Visual clues were more accurate and used todevelop some sense of position in space but thisstill remained a weakness.

5. There was no change in his balance mechanism,but his general sense of timing and rhythm ofmovement was improved.

6. Fear of heights was not apparent in a widevariety of test situations.

Generally, S. was still hyperactive but able tounderstand himself much better and to compensateat a more mature level for his inadequacies.

In his Occupational Therapy reassessment, hebhowed considerable improvement in scores on MotorPlanning tests.

SUMMARY

In this article we have looked at the de­velopment of perceptual-motor learning, andat dysfunctions caused by interference withthe normal course of development. We havepresented various approaches which are cur-

Aust. J. Physiother., XVII, 3, September, 1971..

rently popular and introduced briefly theremedial programme entailed in these ap­proaches. We have established our own posi­tion with respect to early recognition and as­sessment of the signs of perceptual-motorproblems. Further evidence has been cited tosupport the importance of abnormality ofocular control as a sign of dysfunction. Theauthors' recent study investigating the rela­tionship between abnormal head-righting re­flexes and.. the presence of perceptual-motorproblems is also presented. A case study isdiscussed to elucidate the methods of assess­ment and treatment established and used bythe authors.

BIBLIOGRAPHY

ABERCROMBIE, M. L. J. (1964), Perceptual andVisuomotor Disorders in Cerebral Palsy. LittleClub Clinics in Developmental Medicine, II. W.I-Ieinemann, London.

AYRES, J~ (1966), Southern California Kinaesthesiaand Tactile Perception Tests. (M1anual) WesternPsyohological Services, California, U.S.A.

AYRES, J. (1964), Southern California Motor Ac­curacy Test. (Mannal) Western Psychological Ser­vices, California, U.S.A.

AYRES, J. (1966), Southern California Figure-GroundPerception Test, Western Psychological Services,California, U.S.A.

AYRI:S, J. (1962), Space Test. Western PsychologioalServices, California, U.S.A.

BOBATH, B. (1968), Abnormal Postural ReflexesActivity Caused by Brain Lesions. William Heine·mann Medical Books, London.

BRI;RETON, B. LE GAY, and SATTLER, JENNIFER(1967), Cerebral Palsy: Basic Abilities. The Spas­tic Centre of New South Wales, Mosman, Aus­tralia.

CALDLR, J~ (1970), The Theory .of One of the Per­ceptual Motor Approaches to Learning Disabilities,Newell C. Kephart) Discover, 3, 4.

CRATTY, B. J. (1967), Developmental Sequences ofPerceptual Motor Tasks. Educational ActivitiesInc. Freeport, Long Island, New York, U.S.A.

DENHO:FF, E. (1968), "Motor Development as aFunction of Perception" in Perceptual MotorFoundations: A Multidisciplinary Concern.American Association for Health, Physical Educa­tion and Recreation, Washington, D.C., pp. 49-69.

DENHOFF, E., and ROBINAULT, L P. (1960), CerebralPalsy and Related Disorders-A DevelopmentalApproach to Dysfunction. McGraw-Hill Book Co.,N.Y., Toronto, London.

KLPHART, N. C., and ROACH, E. G. (1966), ThePurdue Perceptual-Motor Survey. Merrill BooksInc., Columbus, Ohio.

DEVELOPMENTAL PERCEPTUAL-MoTOR DISORDERS 95

MORDOCK, J. B. (1971), "Behavioural Problems ofthe Child with Minimal Cerebral Dysfunction,"Physical Therapy, 51, 4 : 398-404.

O'DOHERTY, N. J., "Neurological Foundations ofMotor Behaviour in Infancy," Physiotherapy, 57,4: 144.

THOMAS, A., and AUTGAERDON, S. (1966), "Locomo~tion from Pre to Post Natal Life," Clinics in De~velopmental Medicine, 24. W. Heinemann, London.

VERNON, M. D. (1968), The Psychology of Percep­tion. Penguin Books.

Aust. J. Physiother., XVII, 3, September, 1971.