Infant Behavior & Development 46 (2017) 1–6

Contents lists available at ScienceDirect

Infant Behavior and Development

Full length article

Sensory processing disorders in children with cerebral palsy

Sílvia Leticia Pavão (MSc) ∗ , Nelci Adriana Cicuto Ferreira Rocha (PhD)
Department of Physiotherapy, Neuropediatrics Section, Federal University of São Carlos, Rod. Washington Luis, km 235, 13565-905, São
Carlos-SP, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To evaluate sensory processing in children with CP using the Sensory Profile
Received 29 October 2015 questionnaire and to compare results with the ones of children with typical development
Received in revised form 4 August 2016 (TD).
Accepted 28 October 2016
Methods: We assessed sensory processing of 59 TD children and 43 CP children using the
Sensory Profile, a standardized parent reporting measure that records children’s responses
Keywords: to sensory events in daily life. Mann-Whitney test was used to compare the results of
Sensory processing
sensory processing evaluation among the groups. Bonferroni correction was applied.
Cerebral palsy
Results: We found differences in sensory processing between groups in 16 out of the 23
Sensory profile
Children categories evaluated in the Sensory Profile.
Physical therapy Conclusion: Our results pointed out to the existence of disturbances in the processing of
sensory information in CP. Based on the importance of the sensory integration process for
motor function, the presence of such important disturbances draw the attention to the
implementation of sensory therapies which improve function in these children.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction

The motor disorders in children with cerebral palsy (CP) are often accompanied by disturbances of sensation, perception,
cognition, communication and behavior (Bax et al., 2005). Some of the most important determinants of sensory deficits
are the white matter lesions, present in 45% of the children with CP (Reid, Dagia, Ditchfield, Carlin & Reddihough, 2013).
The destruction of white matter can have secondary effects on the development of cortical and thalamic regions, which
are responsible for sensory processing (Tsao, Pannek, Fiori, Boyd & Rose, 2014). Other factors present in CP, such as the
neuromuscular deficits, can contribute to these sensory impairments since they restrict the child’s level of activity (Dos
Santos, Pavão & Rocha, 2011).
Sensory impairments may coexist with motor disabilities in children with CP and may contribute to the motor dysfunction
observed in these children (Pavão, Silva, Savelsbergh & Rocha, 2015). The success in the performance of motor tasks depends
on the quality of afferent inputs which act providing feedback and guiding motor function in order to correct potential motor
mistakes (Dunn & Daniels, 2002; Mulligan, 1995; Papadelis et al., 2014).
Sensory impairments in CP are widely discussed in literature (Bleyenheuft & Gordon, 2013; Cascio, 2010; De Campos,
Kukke, Hallet, Alter & Damiano, 2014). The main reported disturbances in this population are deficits in stereognosis (Kingles
et al., 2010), tactile discrimination and proprioception (Bleyenheuft & Gordon, 2013). However, there seems to be a lack of
studies addressing sensory processing disturbances in CP.

∗ Corresponding author.
E-mail address: silvia pavao@hotmail.com (S.L. Pavão).

http://dx.doi.org/10.1016/j.infbeh.2016.10.007
0163-6383/© 2016 Elsevier Inc. All rights reserved.
2 S.L. Pavão, N.A.C.F. Rocha / Infant Behavior & Development 46 (2017) 1–6

Sensory processing involves registration and modulation of sensory information, as well as an internal organization
of afferent inputs in order to provide adaptive behaviors and success in the performance of tasks (Humphry, 2002). The
registration process involves the perception of the sensory stimuli by the central nervous system (CNS). Modulation process
is the brain’s regulation of neural messages providing the balance between excitation and inhibition based on the available
stimuli (Dunn, 1999). An adequate sensory integration of afferent inputs ensures children present an adaptive behavior in
tasks of daily routine and meet the demands imposed by the environment. Thus, suitable sensory integration promotes
functional performance (Dunn, 1999; White, Mulligan, Merrill & Wright 2007).
Therefore, deficits in sensory processing are believed to affect the way a child behaves, including his or her ability to attend,
learn, organize (Dunn & Daniels, 2002), as well as they can affect the children’s ability to perform motor and functional tasks
achieving adaptive success (Mulligan, 1995; Pavão et al., 2015; White et al., 2007). Thus, the systematic evaluation of sensory
processing allows therapists to adapt their intervention improving sensory integration of the inputs constantly received from
the environment in order to improve motor performance and adaptive success of children with CP (Schhaf & Miller, 2005).
Some procedures of assessment can be used to identify sensory processing disorders, including child and caregiver
interview, formal standardized assessments of sensory processing abilities and clinical observations. Identification of these
disorders is generally through observation of behavioral difficulties such as responding to touch aggressively, withdrawing
from or failing to respond to sensory input (Ayres, 1989; Dunn 1994, 1997, 1999).
In fact, there is a lack of instruments assessing sensory processing in literature (Pavão et al., 2015). This lack is even greater
considering children evaluation. Sensory Profile is one of the most complete available validated checklists that measures
integrative sensory processing (Dunn & Daniels, 2002; White et al., 2007). It is a parent reporting measure that records
children’s responses to sensory events in daily life (Dunn & Brown, 1997).
We selected this instrument for our study because it is psychometrically sound; quick to administer, score, and interpret;
and most important because it was designed specifically to measure “children’s sensory processing abilities that support or
interfere with functional performance” (Dunn, 1999) and allows professionals to use in clinical environment. Although we
have used an instrument that relies exclusively on a third-party retrospective report, rather than a direct measure of sensory
processing capacity or even a direct observational measure of child behavior, this tool is a validated instrument (Dunn, 1999).
In addition, sensory processing is a neurological process that cannot be measured directly, so, caregivers are asked to rate
child behaviors believed to be associated with sensory processing (White et al., 2007).Although the Sensory Profile has been
used in the literature with children presenting different types of developmental disorders (Mulligan, 1995; Schaaf & Miller,
2005; Tomchek & Dunn, 2007), we did not find studies that have used this instrument to evaluate and characterize sensory
processing in children with CP.
Taking into account the reported sensory deficits in CP (Kulak, Sobaniec, Kuzia & Bockowski, 2006; Pavão et al., 2015)
and their potential repercussions on activity level and social participation (Dunn & Daniels, 2002; Pavão et al., 2015; White
et al., 2007), it seems to be important the implementation of a proper evaluation of sensory processing in these children.
Therefore, the objective of this study was to evaluate sensory processing in children with CP using the Sensory Profile
and to compare the results with the ones of children with typical development in order to outline the sensory processing
impairments observed in CP. We expect that children with CP exhibit a large amount sensory processing disorders compared
with typical ones, which can constrain their daily life activities.

2. Methods

2.1. Participants

All the participants were recruited from kindergarten, regular schools or rehabilitation centers specialized in children
care. Only participate in the study children who received parental consent to participate. This study was approved by the
local Ethics Committee (CAAE 17495213.8.0000.5504).
Two groups of participants were evaluated. The control group was composed by 59 children, 31 male and 28 female,
aged from 3 to 15 years-old (M = 8.9 ±3.4 years). Participants with orthopedic conditions which limited physical activity or
diagnosed developmental alterations were excluded from the study.
The experimental group consisted of 43 children with spastic CP, 26 male and 17 female, aged between 3 and 15 years-old
(M = 9.09 ± 3.4). All the participants were classified by the Gross Motor Function Classification System (GMFCS) as level I
(19 children), level II (10 children), level III (seven children), level IV (three children) and level V (three children). GMFCS
represents a functional classification of children with CP, which aims to determine the level of the child based on their
abilities and limitations to perform gross motor function activities. Children can be classified according with five levels as
follows: level I represents the ability to walk without limitations, level II indicates the ability to walk with limitations, level
III is consisted of children that walk using a handheld mobility device; level IV includes children that present self-mobility
with limitations, and level V is composed by children that are transported in a manual wheelchair (Palisano, Rosenbaum,
Bartlett, & Livingston, 2008). We did include neither children who were not regularly inserted in rehabilitation programs at
last twice a week nor children with other comorbidities besides CP.
 S.L. Pavão, N.A.C.F. Rocha / Infant Behavior & Development 46 (2017) 1–6 3

2.2. Materials and procedures

Parents or legal responsible for the children were initially contacted, informed about the purposes of our research and
invited to participate in the study. Then, an interview (in person or by means of telephone) was schedule with them in order
to apply the Sensory Profile. All the interviews were conducted by an experienced professional in the area of neuropediatric.
The intra-observer agreement rate was 94%.

2.2.1. Sensory processing evaluation

The evaluation of the sensory processing was performed using the Sensory Profile (Dunn, 1999). Sensory Profile ques-
tionnaire is a standardized parent reporting measure that records children’s responses to sensory events in daily life.
This questionnaire quantifies behaviors associated with sensory processing dysfunction and provides a tool for consistent
measurement of parental perception of these behaviors.
The questionnaire is composed by 125 items that represent 14 functions of sensory processing. Applied to the parents
or caregivers, it Exhibit 5 possibilities of responses ranging from “always” to “never” related with children’s behaviors.
Six of the categories defined by Sensory Profile are related to sensory processing areas: Auditory Processing, Visual Pro-
cessing, Vestibular Processing, Touch Processing, Multi-Sensory Processing, and Oral Sensory Processing. Five categories
relate to sensory modulation: Modulation Related to Body Position and Movement, Modulation of Movement Affecting
Activity Level, Modulation of Sensory Input Affecting Emotional Responses, Modulation of Visual Input Affecting Emotional
Responses, and Sensory Processing Related to Endurance/Tone. The last three categories reflect social–emotional responses
related to sensory processing: Emotional/Social Responses, Behavioral Outcomes of Sensory Processing, and Thresholds
for Response. In addition to scores generated for these categories, the test provides 9 Sensory Profile Factor scores that
represent sensory processing styles: Sensory Seeking, Emotional Reactivity, Low Endurance/Tone, Oral Sensory Sensitivity,
Inattention/Distractibility, Poor Registration, Sensory Sensitivity, Sedentary, and Fine Motor/Perceptual.
Sensory category and factor scores are interpreted based on the normative data as being either “typical performance”
(within 1 standard deviation from the mean), “probable difference” (between 1 and 2 standard deviations below the mean),
or within the “definite difference” range (more than 2 standard deviations below the mean) (Dunn, 1999).

2.3. Data analysis

Descriptive results were generated by calculating the means and standard deviation. Data distribution was tested for
normality using Shapiro-Wilk W which revealed the absence of normality in the distribution of the data (p ≥ 0.05). The Mann-
Whitney test was used to compare the results of sensory processing evaluation among the groups. Bonferroni correction was
applied to multiple comparisons. The effect size was calculated for each of the conducted analysis. All statistical analyses
were performed using SPSS software for Windows version 17.0 (SPSS Inc. Chicago, IL, USA). The significance level ␣ was set
at p ≤ 0.0021 for all analyses.

3. Results

The characterization of the sample, as well as the confidence interval for the score in each of the evaluated categories
in Sensory Profile for both groups and the statistic differences between groups found in Sensory Profile categories can be
observed in Table 1. The power of the statistical tests performed was 75%.
Children with CP presented worse sensory processing compared with typical children. The disorders children with CP
exhibited were found in the following items of Sensory Profile’s categories:

- Disturbances in the following areas of Sensory Processing (Visual; Vestibular; Multi-Sensory);

- Disturbances in modulation of Sensory Processing (Sensory Processing Related to Endurance/Tone; Modulation Related to
Body Position and Movement; Modulation of Sensory Input Affecting Emotional Responses);
- Disturbances in social-emotional responses to Sensory Processing (Emotional/Social Responses; Behavioral Outcomes of
Sensory Processing; Thresholds for Response)
- Impairments in Factors representing Sensory Processing styles (Low Endurance/Tonus, Inattention/Distractibility; Poor
Registration; Sensory Sensitivity; Sedentary; Fine Motor/Perceptual);

4. Discussion

The present study aimed to evaluate sensory processing in children with CP and children with typical development.
We observed that children with CP present important disorders in sensory processing compared with children with typical
development.
Although the deficits in sensory system have been widely reported in children with CP (De Campos et al., 2014;
Bleyenheuft & Gordon, 2013; Cooper, Majnemer, Rosemblatt & Birnbaum, 1995; Klingels et al., 2010), we have found a
few number of studies addressing the sensory processing of these children in the searched literature (Bumin & Kayohan,
2001; Papadelis et al., 2014). Papadelis et al. (2014) and Bleyenheuft and Gordon (2013) report the existence of disturbances
4 S.L. Pavão, N.A.C.F. Rocha / Infant Behavior & Development 46 (2017) 1–6

Table 1
Characteristics of the groups according to confidence intervals (CI) of the evaluated areas in Sensory Profile and differences between groups found in
Sensory Profile categories.

Categories Control CP Group Test Level of Z-score Effect size

Group (CI) (CI) Statistic (U) Significance (p) (r)

Sensory Processing Areas

Visual Processing [1.16–1.45] [1.54–2.03] 834 p < 0.002* −3.27 −0.32
Auditory Processing [1.34–1.72] [1.73–2.22] 867 0.005 −2.82 −0.27
Vestibular Processing [1.78–2.24] [2.31–2.75] 840 p < 0.002* −3.03 −0.3
Touch Processing [1.59–1.98] [1.86–2.32] 0.05 −1.97 −0.19
Multi-Sensory Processing [1.3–1.69] [2.24–2.73] 529 p < 0.002* −5.35 −0.53
Oral-Sensory [1.29–1.66] [1.45–1.94] 1068 0.16 −1.38 −0.13

Sensory Modulation
Modulation Related to Body Position and Movement [1.49–1.88] [2.51–2.88] 422 p < 0.002* −6.04 −0.6
Modulation of Movement Affecting Activity Level [1.3–1.63] [1.86–2.36] 709 p < 0.002* −3.99 −0.39
Modulation of Sensory Input Affecting Emotional Responses [1.19–1.56] [2.3–2.76] 408 p < 0.002* −6.29 −0.62
Sensory Processing Related to Endurance/Tone [0.99–1.21] 3 43 p < 0.002* −9.49 −0.94
Modulation of Visual Input Affecting Emotional Responses [2.14–2.58] [2.42–2.82] 1049 0.11 −1.6 −0.15

Social-Emotional Responses
Emotional/Social Responses [1.55–1.96] [2–2.46] 842 p < 0.002* −2.95 −0.29
Behavioral Outcomes of Sensory Processing [1.16–1.49] [1.91–2.45] 606 p < 0.002* −4.93 −0.49
Thresholds for Response [0.96–1.1] [1.27–1.65] 782 p < 0.002* −4.79 −0.47

Sensory Profile Factors

Sedentary [1.25–1.64] [1.9–2.46] 715 p < 0.002* −4.06 −0.4
Fine motor/Perceptual [0.98–1.18] [1.71–2.32] 636 p < 0.002* −5.51 −0.54
Low Endurance/Tonus [0.9–1.21] [2.8–3.04] 73 p < 0.002* −9.27 −0.92
Inattention/Distractibility [1.5–1.94] [2.07–2.62] 789 p < 0.002* −3.4 −0.33
Poor Registration [1.08–1.36] [1.39–1.86] 877 p < 0.002* −3.16 −0.31
Sensory Sensitivity [1.05–1.32] [1.98–2.52] 474 p < 0.002* −6.12 −0.6
Sensory Seeking [1.7–2.2] [1.7–2.26] 1233 0.9 −0.1 −0.009
Emotional Reactivity [1.53–1.91] [2.07–2.53] 744 0.05 −3.67 −0.36

in the processing of sensory information in CP. Nevertheless, none of the founded studies reported the evaluation of the
children’s ability to process and modulate sensory information.
We observed that children with CP, compared to typical children, present most pronounced impairments in visual,
vestibular and multisensorial processing. These sensory processing impairments seem to be related to an abnormal mech-
anism in the sensoriomotor network of children with CP, as a possible result of diminished thalamocortical projections
(Papadelis et al., 2014). These structural deficits may compromise the processing of tactile and somatosensory information
in children with CP (Reid et al., 2013).
The impaired processing of visual and vestibular information might result in deficits of postural control in children with
CP, since these sources of sensory information are processed in postural control modulation (Pavão et al., 2013). In fact, their
postural control system is more vulnerable to visual and vestibular changes, exhibiting greater body sway compared with
typical children (Pavão et al., 2015).
Modulation of sensorial stimuli was also impaired in children with CP. The areas constrained according to Sensory Profile
were: sensory processing related to tonus and resistance, modulation related to body position and movement, modulation
related to level of activity and modulation of sensory input affecting emotional responses. The reduced levels of endurance
and physical activity, as well as the disturbances involving the position of body in space, deficits in movement and tonus
regulation observed in children with CP seems to be consequences not only of the impairments in their motor system,
but also result of impaired modulation of sensory inputs. In fact, the impaired balance between excitation and inhibition
based on the available stimuli (Dunn, 1999), might constrain motor planning, behavior and cognition (Blanche, Botticelli &
Hallway, 1995; Ayres, 1989). This imbalance might even disturb emotional responses of these children, influencing their
self-confidence and affective behavior, as well as interfering with their adaptation to different environments (Dunn, 1999;
White et al., 2007).
Children with CP presented most pronounced deficits in behavioral and emotional responses resulting from sensory
processing. This result indicates that deficits in sensory processing can interfere with social and emotional behavior more
deeply in children with CP, than in children with typical development.
Lastly, children with CP presented important impairments in sensory processing which determine defined sensory styles.
They exhibit altered tonus regulation, exhibiting low resistance and muscle weakness during physical activities. These
children also presented high level of inattention and distractibility in everyday activities, difficulties to register sensory inputs
(specialy visual and tatil), high sensitivity to stimuli involving head position in space and impaired fine motor coordination.
Accordingly, these defined “styles” result in a reduced awareness of all type of sensation available, impairments in their
“interest in” and “pleasure with” a large source of sensation (Dunn & Daniels., 2002) impairing their functional performance
in activities of daily routine (White et al., 2007).
 S.L. Pavão, N.A.C.F. Rocha / Infant Behavior & Development 46 (2017) 1–6 5

The cerebral damage in children with CP is an important determinant in their sensory deficits. According to Wingert,
Sinclair, Dixit, Damiano and Burton (2010), disruptions in parietal and frontal cortical somatosensory regions observed in
CP might be related to deficits in tactile shape and grating discrimination affecting fine motor coordination and sensory
sensitivity.
Based on the sensory evaluation we have performed, children with CP display a greater need for controlling the amount
and type of sensation available any time in order to produce adaptive responses. These children present important alterations
in the processing of the somatosensory cortex (Papadelis et al., 2014), which can explain our results. According to the authors,
these reported alterations are attributed to impaired fibers in white matter connecting to sensory cortex and are also the
result of a reduction of coordinated messages from somatosensory cortex to motor areas.
Recent studies addressing brain image patterns in children with CP reported white matter injuries in about 45% of the
evaluated neuroimaging exams (Reid et al., 2013). The authors suggest that these damages can have secondary effects on
the development of cortical and thalamic regions, partially responsible for sensory processing (Tsao et al., 2014). These
neuroanatomical and neurophysiological reports can be determined as potential causes of the deficits in registration on
sensory stimuli, impairments in motor coordination, fine and gross motor function and motor control observed in children
with CP (Papadelis et al., 2014). These findings suggest that large part of the sensory impairment observed in CP, as the ones
found in the present study, are primary dysfunctions resulted from the CNS damage. Although, these studies have evaluated
cerebral function, none of them in fact evaluated sensory processing in children with CP, assessing children’s behaviors that
indicate dysfunctional sensory profile.
Nevertheless, besides the reported structural damage in the CNS of children with CP (Papadelis et al., 2014; Reid et al.,
2013; Tsao et al., 2014), functional impairments in activity level and social participation might aggravate sensory processing
deficits observed in these children (Dos Santos et al., 2011; Pavão, Nunes, Santos & Rocha, 2014; Pavão, Santos, Oliveira &
Rocha, 2014; Liao & Hwang, 2003), since they restrict sensory exploration of the environment these children are inserted.
The impaired mechanism of strength production (Verschuren et al., 2011), tone regulation (Quinby & Abrahan, 2005)
and neuromuscular control (Barela et al., 2011) affects children’s ability of the children to move and experience the world
around them. These motor constrains limit the performance of activities that provides them a large sort of tactile, synesthetic,
discriminative and proprioceptive sensations (Bleyenheuft & Gordon, 2013). This constrained ability of explore the world
results in impaired mechanisms of perception and modulation of sensory stimuli, altering neurologic thresholds (the amount
of stimuli required for a neuron or neuron system to respond) and restricting their ability to modulate emotional and
behavioral responses (i.e., balance between habituation and sensitization) (Dunn & Daniels, 2002). Therefore, children with
CP exhibit inappropriate responses to stimuli in the environment.
The understanding of the constraints in activity and participation in children with CP as potential contributors of their
sensory processing deficits is related to the concepts of developmental processes encompassed by the Dynamical System
Theory (Smith & Thelen, 2003). According to these theory, the aspects determining the patterns of behaviors presented by
the individuals are conditioned not only to their intrinsic features (such as cerebral damage), but also to the restrictions of
the tasks and of the environment to which they are exposed (Newell, 1986). These statements call attention to the role of
the environmental conditions in children’s development. The volume of stimuli from the environment which children are
exposed to is expected to influence the way them receive and processes sensory information to guide their motor actions
(Papadelis et al., 2014; White et al., 2007).
Based on these statements, the sensory processing impairments observed in children with CP pointed out to the necessity
of submit these children to therapies involving a sensory approach in combination with motor stimulation in order to
promote functional improvements in daily life (Bunin & Kayihan, 2001; Schhaf & Miller, 2005).
The parent’s interview contained in Sensory Profile helps the establishment of a closed and cordial relationship between
therapists and children’s parents which might be a facilitator factor for the improvement in children’s health condition
(Lynch & Hanson, 1992). As soon as the therapists sets children’s caregiver in the center of the therapy (as an important
rehabilitation team member), their involvement with the rehabilitation processes tends to increase, as well as the functional
results of the therapy (Pavão, Silva & Rocha, 2011).
The unequal distribution of the children with CP among the five levels of GMFCS is an important limitation of the present
study. A most homogeneous distribution among the five levels of GMFCS, or at last a larger sample size in the levels IV and
V of GMFCS, could allow a data analysis taking into account the levels of GMFCS, and so wider inferences about our results.
Moreover, the wide age range of our sample may have influenced the results, since during the evaluation children were
experiencing different stages of development.
We believe that a better comprehension of sensory function and also of sensory processing in children with CP is extremely
important, since the somatosensory inputs are essential components of motor function, motor control and development
(Papadelis et al., 2014). An adequate knowledge of the sensory processing deficits in this population allows the professionals
involved with clinical rehabilitation to add specific sensory stimuli in their therapies in order to improve independency and
functionality in children with CP.

5. Conclusion

According to our results, children with CP present important sensory processing deficits compared to typical ones. They
exhibited important impairments in the processing of visual, vestibular and multisensory information, as well as important
6 S.L. Pavão, N.A.C.F. Rocha / Infant Behavior & Development 46 (2017) 1–6

constraints in modulation of sensory information affecting their level of activity, muscle resistance, body position in space
and emotional responses. Together, these impairments determine a sensory style of low resistance, distractibility, poor
registration, sensory sensitivity, sedentary and poor fine motor coordination.

Acknowledgement

The authors declare that the present manuscript was supported financially by a grant from xxxxxxxxxxx.

References
Ayres, A. J. (1989). Sensory integration and praxis tests. Los Angeles: Western Psychological Services.
Barela, J. A., Focks, G. M. J., Hilgeholt, T., Barela, A. M. F., Carvalho, R. P., & Savelsbergh, G. J. P. (2011). Perception-action and adaptation in postural control
of children and adolescents with cerebral palsy. Research in Developmental Disabilities: 32., 2075–2083.
Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., Paneth, N., Dan, B., et al. (2005). Proposed definition and classification of cerebral palsy. Developmental
Medicine and Child Neurology: 47., 571–576.
Blanche, E. I., Botticelli, T. M., & Hallway, M. K. (1995). Combining neuro-developmental treatment and sensory integration principles: An approach to
pediatric therapy. Therapy Skill Builders,. Spiral edition.
Bleyenheuft, Y., & Gordon, A. M. (2013). Precision grip control: Sensory impairments and their interaction in children with hemiplegic cerebral palsy: A
systematic review. Research in Developmental Disabilities: 34., 3014–3028.
Bumin, G., & Kayohan, H. (2001). Effectiveness of two different sensory integration programmes for children with spastic diplegic cerebral palsy.
Dysability & Rehabilitation: 23., (9), 394–399.
Cascio, C. J. (2010). Somatosensory processing in neurodevelopmental disorders. Journal of Neurodevelopmental Disorders: 2., 62–69.
Cooper, J., Majnemer, A., Rosemblatt, B., & Birnbaum, C. (1995). The determination of sensory deficits in children with hemiplegic cerebral palsy. Journal of
Child Neurology: 10., 300–309.
De campos, A. C., Kukke, S. N., Hallet, M., Alter, K. E., & Damiano, D. L. (2014). Characteristics of bilateral hand-function in individuals with unilateral
dystonia due to perinatal stroke: Sensory and motor aspects. Journal of Child Neurology: 29., 623–632.
Dos Santos, A. N., Pavão, S. L., & Rocha, N. A. C. F. (2011). Sit-to-stand movement in children with cerebral palsy: A review. Research in Developmental
Disabilities: 32., 2243–2252.
Dunn, W., & Brown, C. (1997). Factor analysis on the sensory profile from a national sample of children without disabilities. The American Journal of
Occupational Therapy: 51., 490–495.
Dunn, W., & Daniels, D. B. (2002). Initial development of the infant/toddler sensory profile. Journal of Early Intervention: 25., 27–41.
Dunn, W. (1994). Performance of typical children on the Sensory Profile: An item analysis. The American Journal of Occupational Therapy: 48., 967–974.
Dunn, W. (1997). The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model. Infants and Young
Children: 9., 23–35.
Dunn, W. (1999). The sensory profile: Examiner’s manual. San Antonio, TX: Psychological Corporation.
Humphry, R. (2002). Young children’s occupations: Explicating the dynamics of developmental processes. The American Journal of Occupational Therapy:
56., 171–179.
Klingels, K., De Cock, P., Molenaers, G., Desloovere, K., Huenaerts, C., Jaspers, E., et al. (2010). Upper limb motor and sensory impairments in children with
hemiplegic cerebral palsy. Can they be measured reliably? Disability and Rehabilitation: 32., (5), 409–416.
Kulak, W., Sobaniec, W., Kuzia, S. J., & Bockowski, L. (2006). Neurphysiologic and neuroimaging studies of brain plasticity in children with spastic cerebral
palsy? Experimental Neurology: 198., (1), 4–11.
Liao, H. F., & Hwang, A. W. (2003). Relations of balance function and gross motor ability for children with cerebral palsy. Perceptual and Motor Skills: 96.,
1173–1184.
Lynch, E., & Hanson, M. J. (1992). Developing crosscultural competence: A guide for working with children and their families. Baltimore: Paul H. Brookes.
Mulligan, S. (1995). An analysis of score patterns of children with attention disorders on the sensory integration and praxis tests. The American Journal of
Occupational Therapy: 50., 647–654.
Newell, K. (1986). Constraints on the development of coordination. In H. T. A. Wade e (Ed.), Motor development in children: Aspects of coordination and
control (pp. 341–360). Boston, M.A: Martin Nijhoff.
Palisano, R. J., Rosenbaum, P., Bartlett, D., & Livingston, M. H. (2008). Content validity of the expanded and revised gross motor function classification
system. Developmental Medicine and Child Neurology: 50., 744–750.
Papadelis, C., Ahtam, B., Nazarova, M., Nimec, D., Snyder, B., Grant, P. E., et al. (2014). Cortical somatosensory reorganization in children with spastic
cerebral palsy: A multimodal neuroimaging study. Frontiers in Human Neuroscience: 8., 1–15.
Pavão, S. L., Silva, F. P. S., & Rocha, N. A. C. F. (2011). The effect of in-home instruction on the functional performance of children with special needs.
Motricidade: 7., 21–29.
Pavão, S. L., dos Santos, A. N., Woollacott, M. H., & Rocha, N. A. C. F. (2013). Assessment of postural control in children with cerebral palsy: A review.
Research in Developmental Disability: 34., 1367–1375.
Pavão, S. L., Nunes, G. S., dos Santos, A. N., & Rocha, N. A. C. F. (2014). a. Relationship between static postural control and level of functional abilities in
cerebral palsy. Brazilian Journal of Physical Therapy: 18., 300–307.
Pavão, S. L., dos Santos, A. N., Oliveira, A. B., & Rocha, N. A. C. F. (2014). Functionality level and its relation to postural control during sitting-to-stand
movement in children with cerebral palsy. Research in Developmental Disabilities: 35., 506–511.
Pavão, S. L., Silva, F. P. S., Savelsbergh, G. J. P., & Rocha, N. A. C. F. (2015). Use of sensory information during postural control in children with cerebral palsy:
Systematic review. Journal of Motor Behavior, 1–11.
Quinby, J. M., & Abrahan, A. (2005). Musculoskeletal problems in cerebral palsy. Current Pedia: 15., 9–14.
Reid, S. M., Dagia, C. D., Ditchfield, M. R., Carlin, J. B., & Reddihough, D. S. (2013). Population-based studies of brain imaging patterns in cerebral palsy.
Developmental Medicine and Child Neurology: 56., 222–232.
Schaaf, R. C., & Miller, L. J. (2005). Occupational therapy using a sensory integrative approach for children with developmental disabilities. Mental
Retardation and Developmental Disabilities Research Reviews: 11., 143–148.
Smith, L. B., & Thelen, E. (2003). Development as a dynamic system. Trends in Cognitive Science: 7., (8), 343–348.
Tomchek, S. D., & Dunn, W. (2007). Sensory processing in children with and without autism: A comparative study using the Short Sensory Profile.
American Journal of Occupational Therapy: 61., 190–200.
Tsao, H., Pannek, K., Fiori, S., Boyd, R. N., & Rose, S. (2014). Reduced integrity of sensorimotor projections traversing the posterior limb of the internal
capsule in children with congenital hemiparesis. Research in Developmental Disabilities: 35., 25–260.
Verschuren, O., Ada, L., Maltais, D. B., Gorter, J. W., Scianni, A., & Ketelaar, M. (2011). Muscle strengthening in children and adolescents with spastic
cerebral palsy: Considerations for future resistance training protocols. Physical Therapy: 91., (7), 1–10.
White, B. P., Mulligan, S., Merrill, K., & Wright, J. (2007). An Examination of the relationships between motor and process skills and scores on the sensory
profile. The American Journal of Occupational Therapy: 62., 154–160.
Wingert, J. R., Sinclair, R. J., Dixit, S., Damiano, D. L., & Burton, H. (2010). Somatosensory-evoked cortical activity in spastic diplegic cerebral palsy. Human
Brain Mapping: 31., 1772–1785.