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The use of the QNST–II as a measure for the identification of children with
perceptual-motor deficits

Article  in  Occupational Therapy International · August 2002

DOI: 10.1002/oti.164 · Source: PubMed

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Occupational Therapy International, 9(3), 185–200, 2002 © Whurr Publishers Ltd 185

The use of the QNST–II as a

measure for the identification of
children with perceptual-motor
deficits

SHULA PARUSH School of Occupational Therapy, Hebrew University of

Jerusalem, Israel
ARTAL RILSKY School of Occupational Therapy, Hebrew University of
Jerusalem, Israel
SARINA GOLDSTAND School of Occupational Therapy, Hebrew University
of Jerusalem, Israel
TAL MAZOR-KARSENTY School of Occupational Therapy, Hebrew
University of Jerusalem, Israel
AVIVA YOCHMAN School of Occupational Therapy, Hebrew University of
Jerusalem, Israel

ABSTRACT: This study aimed to examine the ability of the Quick Neurological
Screening Test–II (QNST–II) (Mutti et al., 1998) to discriminate between children
with and without perceptual-motor deficits and to further clarify its psychometric char-
acteristics. Ninety-four children aged six to seven years were tested on the QNST-II.
Out of this pool of subjects, 63 children had perceptual-motor deficits and 31 were typi-
cal controls. The children with perceptual-motor deficits scored significantly lower than
the control children on the total score and on each of the subtest’s scores of the
QNST–II. Inter-rater reliability indicated a high degree of correlation between both
evaluators’ total scores of the QNST–II. In terms of the test’s sensitivity and specificity,
QNST–II scores correctly classified 97% of the children with perceptual-motor deficits
and 84% of the children from the control group. The findings of this study support the
capability of the QNST–II to discriminate between children with perceptual-motor
deficits and typical children; thereby suggesting its usefulness as a screening measure to
identify children at risk for difficulties in school performance.

Key words: perceptual-motor deficits, Quick Neurological Screening Test–II.

Introduction
All children are expected to spend considerable time in an educational set-
ting in preparation for adult roles in life. Since the passing of federal laws
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186 Parush et al.

mandating that free, appropriate education be provided to all children regard-

less of the existence of a handicapping or disabling condition, a significant
portion of the practice of paediatric occupational therapy has shifted from
medical to school settings (Coutinto and Hunter, 1988; Niehues et al., 1991;
Coster, 1998; Mellard, 2000). Function in performance areas is the ultimate
concern in occupational therapy (American Occupational Therapy Associa-
tion, 1994; Coster, 1998). This perspective is in keeping with modern federal
requirements that school-based service providers identify specific functional
outcomes and goals for the children being serviced (Giangreco, 1995; Mellard,
2000). Therefore, occupational therapists in educational settings have begun
to refocus service provision to incorporate the profession’s emphasis on occu-
pation and functioning (American Occupational Therapy Association, 1989;
Coster, 1998; Baum, 2000; Dunn, 2000a).
Young children entering school are expected to perform a multitude of new
tasks and demands in order to function adequately in the occupational perfor-
mance area represented by school. As paediatric occupational therapists, it is
appropriate that we use our professional expertise to identify potential perfor-
mance difficulties early in order to identify children at risk for performance
difficulties, so that they can receive appropriate support before problems occur
(Dunn, 2000b).
Dunn (2000b) highlights the importance of screening performance features
that are prevalent among a target population and that may have a significant
impact on performance and function. In her judgement early school screening
is justifiable in light of the great number of developmental issues that have the
potential to negatively impact school performance (Dunn, 2000b). Paediatric
professionals in various disciplines, who believe it is important to identify
early on children whose development is at variance with developmental
norms and expectations, share this opinion. The rationale they present for
early identification is based on the assumption that developmental processes
are more flexible in the young child and that monitoring and supportive inter-
vention may prevent the onset of secondary problems such as social and
emotional difficulties. Indeed, early screening of children at risk for school dif-
ficulties is of great interest to school therapists, because the ramifications of
limited occupational performance and participation in school can extend to
occupational performance beyond (Gallagher, 1973; Henderson & Hall, 1982;
Dworkin, 1986; McLaughlin & Wehman, 1992). Finally, screening is also an
effective technique that fits with the emphasis being placed on preventative
services in the newly evolving paradigm of health care (Baum, 2000).
Because screening is often the first contact the child’s family has with the
educational system, it is important that the information the family receives is
accurate and helpful (Dunn, 2000b). Furthermore, it is vital that professionals
bear in mind the need to include items that examine performance compo-
nents considered to underlie the desired functional outcome. As occupational
therapists, we view sensory and perceptual-motor abilities as being important
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Using the QNST–II to identify perceptual-motor deficits 187

foundational skills for the attainment of end-product abilities (that is, praxis,
visual perception, language and articulation abilities, behaviour, activity level,
and emotional tone) that are crucial for a child’s school performance (Royeen
& Marsh, 1988; Dunn, 1992; Duncan, 1998; Parham, 1998; Spitzer & Roley,
2001). The correlations that exist between these sensory-motor-perceptual
abilities and school performance have been well verified in the scientific liter-
ature (Polatajko et al., 1991; Taylor et al., 1995; Fletcher-Flinn et al., 1997;
Sugden and Chambers, 1998; Haskell, 2000; Rosenbaum et al., 2001), and in
addition, research has shown that skill level in these areas can reliably dis-
criminate between children with and without learning impairments
(Rosenberg, 1989; Chiarenza, 1990; Murray et al., 1990; Fisher and Murray,
1991; Summerfield & Michie, 1993).
However, for a screening test to be useful, it must have adequate validity
and reliability to have confidence in the scores produced and in their accurate
interpretation (Gredler, 1992; Bundy, 1995).
The Quick Neurological Screening Test–II (QNST–II) (Mutti et al.,
1998) is a standardized test that various occupational therapy references have
recommended to be included in the assessment process when academic func-
tion is under consideration (Rogers, 1987; Stewart, 1996; Wilson, 1998;
Dunn, 2000b). The authors of the QNST–II assert that the test is meant to
evaluate the neurological integration of sensorimotor and perceptual-motor
performance abilities as they relate to learning (Mutti et al., 1998). In
attempting to validate this statement, Sterling and Sterling (1977) examined
the performance on the QNST of 66 children with poor academic achieve-
ment. Forty-two of the 44 subjects with auditory perceptual problems had
poor balance in the appropriate QNST tasks (that is, standing on one leg,
tandem walk, arm and leg extension, and/or skipping). Overall, moderate to
severe impairment was found among 44 of the students, and eight others
showed slight impairment, indicating that QNST findings confirmed percep-
tual and motor difficulties among 52 of the 66 subjects with known difficulties
in school function.
The usefulness of the QNST–II is due, in part, to its practicality: it is brief,
relatively simple to administer, inexpensive and does not require the use of
special equipment that would hamper its usefulness among itinerant occupa-
tional therapists (Mutti et al., 1998). However, the decision to use an
evaluation tool must also focus on its available psychometric data (Bundy,
1995). Careful review of the literature has revealed a dearth of studies dedi-
cated to this purpose for the QNST–II (Yamahara, 1972; Geiser, 1976;
Sterling and Sterling, 1977, 1980; Finlayson and Obrzut, 1993; Mutti et al.,
1998). In addition, a screening tool whose psychometric properties show sta-
bility across cultures instils confidence in the decisions that are made based
on its results.
Thus, the purposes of the study were to: 1) demonstrate the usefulness of the
QNST–II in discriminating between children with and without perceptual-
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188 Parush et al.

motor deficits, factors known to highlight those children who may be at risk for
future functional disabilities, and 2) further clarify the psychometric capabilities
of the QNST–II.

Method

Subjects

The subjects included 94 children aged six to seven years: 63 children with
perceptual-motor deficits (PMD) and 31 typically developing children that
were randomly selected from public schools in Jerusalem. Boys comprised 65%
of the experimental group and 64.5% of the control group. Each of the typi-
cally developing subjects was matched for gender, age and neighborhood with
at least one of the subjects diagnosed with perceptual-motor deficits. No sta-
tistical differences were found in gender, age, or neighborhood, between the
comparison groups.
Inclusion criteria for this study stipulated that all the children had normal
intelligence, and did not have significant physical dysfunction (such as cere-
bral palsy and spina bifida), behavioural or emotional problems, hearing
impairment, and had normal to corrected-normal vision. Additional criteria
for the control children were that they were born at term without apparent
abnormal prenatal or perinatal history, had no perceptual-motor or speech
delay and had not received any treatment by a speech pathologist, occupa-
tional and/or physiotherapist, psychologist or any other professional related to
developmental deficits. Experienced paediatric clinicians selected subjects eli-
gible for inclusion in the PMD group, determined through the administration
of well-established standardized developmental assessments, including the
Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI)
(Beery, 1989), the Motor-Free Visual Perception Test – Revised (MVPT – R)
(Colarusso and Hammill, 1996), the Bruininks-Oseretsky Test of Motor Profi-
ciency (BOTMP) (Bruininks, 1978) and selected subtests of the Southern
California Sensory Integration Tests (SCSIT) (Ayres, 1980). According to the
study’s protocol, the requisite inclusion criteria for children in the PMD group
were that subjects had clear impairments in a minimum of three areas of func-
tion: a) gross and/or fine motor performance, b) visual motor integration, c)
visual and/or auditory perception, d) tactile discrimination, e) praxis, and f)
vestibular-proprioceptive processing (see Table 1).

Instrument
The QNST was published in 1974 and revised in 1978. In 1998 the authors
published an updated QNST test manual (QNST-II) that includes a compila-
tion of the latest information regarding the association between neurological
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Using the QNST–II to identify perceptual-motor deficits 189

TABLE 1: Deficit areas in children with PMD (%)

Deficit area %

Gross motor 57
Visual-motor integration 58
Fine motor 58
Tactile discrimination 25
Praxis 48
Vestibular-proprioceptive 46

soft signs and learning disabilities and innovations regarding educational

implications (Mutti et al., 1998). In addition to the new information provid-
ed in the QNST–II manual, the authors made minor revisions in the
instructions for test administration and scoring protocol for enhanced clarity.
The only change to the original test format of the QNST–II is the sequence
with which geometric figures are presented in the figure-copying subtest.
Specifically, the position of the diamond and rectangle have been switched in
order to reflect the developmental progression of figure-copying abilities.
The QNST–II contains 15 subtests compiled from among tasks commonly
found in neurological and neuropsychological test batteries. Analysis of the
subtests shows that the following performance components are included:
motor and sensory maturity, motor planning, vestibular and kinaesthetic func-
tion, tactile discrimination, processing and modulation ability, rhythmic and
sequencing abilities, fine and gross motor coordination, laterality, eye–hand
skill, hand preference, visual-motor coordination and visual function, audito-
ry perception and auditory-motor skills, behavioural adaptation and coping
skill, and attention span (Mutti et al., 1998). Sterling and Sterling, cited in
the QNST–II manual (Mutti et al., 1998: 47–8), have outlined these process-
ing skills as among those most essential for academic success.
The QNST–II assesses subtest performance using a variety of criteria that
are scored as follows: a score of 1 is assigned to each criterion of the observed
performance that can be indicative of a developmental discrepancy. Achiev-
ing a score of 1 is considered less serious and not necessarily indicative of
neurological pathology. In contrast, a score of 3 is reserved for subtest perfor-
mance showing severe impairment and can indicate atypical development.
The summed score for each subtest is derived from adding together the points
accrued during subtest performance. The possible ranges for the summed
scores therefore depend on the number of criteria by which the quality of sub-
test performance is judged and the scored points received for each. The total
overall test score is a summation of subtest scores. In addition, it can be scored
by categorizing resulting scores as SD (severe discrepancy, with maximum
total test scores that can exceed 50), MD (moderate discrepancy, with maxi-
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190 Parush et al.

mum total scores reaching from 26 to 50) or NR (normal range score, with
maximum total scores of 25 or less). Test administration requires no more
than 20–30 minutes and no special materials are needed (apart from a pen,
table, chair and a large room in a relatively quiet testing environment).
The QNST–II authors posit that because the neurological functions
assessed have not changed since the original tool was developed, the original
psychometric data on which the scoring criteria are based are still valid. Thus,
the test–retest reliability coefficient reported for the QNST and the QNST–II
is r = 0.81 (Yamahara, 1972). Interrater reliability between experienced exam-
iners yielded a coefficient of 0.71 (Geiser, 1976).
Finlayson and Obrzut (1993) studied the construct validity of the QNST
through analysis of its factorial structure. Their findings led them to conclude
that the test measures fine and gross motor control, as well as sensory and per-
ceptual processes, which are considered to underlie the development of
higher-order cognitive skills.
Concurrent validity studies were performed, comparing scores on the
QNST with those on a number of developmental and academic achievement
tests (that is, subtests of the Bender Visual Motor Gestalt Test, WRAT Read-
ing and Spelling subtests, PIAT Math and Reading subtests, Denver
Developmental Screening Test, Nelson-Denny Reading Test and the Modern
Language Aptitude Test). Moderate correlations were found between these
tests and scores on the QNST (Mutti et al., 1998).

Procedure

Testing was identical for both the PMD and control groups. Each subject was
tested individually in a separate quiet room, according to the standardized
procedure. All testing was done in one session and took about 30 minutes for
each child.
Of the 63 subjects with perceptual-motor deficits, 11 children were ran-
domly selected to test interrater and test–retest reliability. For interrater
reliability the QNST–II was administered by a primary investigator, who fol-
lowed the examiner’s manual guidelines, while a second evaluator observed
and scored the child’s performance independently.
Test–retest reliability was conducted after a 30-day interval, on the same
11 children, using the same procedures that were used in the first testing ses-
sion. Subjects were retested by the same primary investigator who performed
the first test.

Statistical analysis
To test internal consistency Cronbach’s alpha (Cronbach, 1970) was imple-
mented between test items. Pearson correlation coefficients were computed to
estimate interrater and test–retest reliability between first and second evalua-
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Using the QNST–II to identify perceptual-motor deficits 191

tor and first and second test results respectively. To compare both groups’ test
performance, t-tests and chi-square statistics were used according to the scale
of test items.
To determine whether items on the QNST–II cluster meaningfully into
independent groupings, a principal component factor analysis was used. The
factor analysis was restricted to 5 factor solutions, testing their correspon-
dence to test structure. All factors reported were required to achieve
eigenvalues above 1.0, which suggests that they account for meaningful
amounts of the variance in the 16 items. To increase the interpretability of
the factors, a Varimax orthogonal rotation was conducted. Sensitivity and
specificity were calculated based on Bayem’s theory, which provides a method
for calculating conditional probability (Law and Polatajko, 1987).

Results

Because boys outnumbered girls in both groups, the difference in the perfor-
mance level of boys and girls in each group was examined through
MANOVA. The findings were that gender had no significant effect on the
total score and on any subtest score of the QNST–II (F (1,54) = 0.988; p =
0.33). In addition, no significant interaction was found, showing that boys
and girls behave the same in each group. Therefore, all statistical analyses
were conducted on the entire group, without differentiating boys from girls.
Internal consistency was computed through Cronbach alpha, which yielded
α = 0.85 for both groups of children. Pearson correlation coefficient comput-
ed for interrater reliability indicated a high degree of correlation (r = 0.89;
p < 0.001) between both evaluators’ total scores of the QNST–II. Correlation
between both testing sessions for test–retest reliability was significant with
relatively medium magnitude (r = 0.63; p < 0.05).
Results of t-test analyses for summed weighted scores indicated that the
children with perceptual-motor deficits scored significantly higher totals and
on each of the subtests (Table 2). Chi-square analyses were performed to com-
pare the assigned categorization (1 = normal range, 2 = moderate discrepancy,
and 3 = severe discrepancy) for children with and without perceptual-motor
deficits. As can be seen from Table 3, a significantly higher percentage of chil-
dren in the control group scored in the normal range or with moderate
discrepancy than the children with PMD.
Table 4 lists the items of each factor and their loadings in descending
order. All QNST–II items loaded above 0.45 and each was centrally related to
a single factor, making the interpretation of clustering simpler.
In term of the test’s sensitivity, 97% of the children in the PMD group
were correctly classified by their QNST–II scores as having perceptual-motor
problems. In terms of specificity, 84% of the children from the control group
were classified as not having perceptual-motor problems. When taking both
groups into account, 95% of the children were correctly classified.
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192 Parush et al.

TABLE 2: Comparison of summed weighted scores between groups on the QNST–II

Subtest Group n Mean SD t

1 PMD 63 1.48 1.18 3.58 **

Control 31 0.65 0.76
2 PMD 63 4.48 2.43 7.00 **
Control 31 1.19 1.36
3 PMD 56 5.32 2.06 6.15 **
Control 31 2.39 2.25
4 PMD 63 3.70 2.75 3.24 *
Control 31 1.84 2.33
5 PMD 62 6.70 3.15 5.89 **
Control 31 2.87 2.50
6 PMD 63 3.16 2.65 5.07 **
Control 31 0.65 1.05
7 PMD 62 3.84 1.78 7.11 **
Control 31 1.35 1.08
8 PMD 63 1.98 1.89 4.14 **
Control 31 0.12 0.81
9 PMD 63 2.25 1.88 4.18 **
Control 31 0.74 1.00
10 PMD 60 5.70 2.85 6.48 **
Control 31 1.65 2.78
11 PMD 63 4.78 2.37 4.49 **
Control 31 2.61 1.80
12 PMD 63 2.03 1.02 6.73 **
Control 31 0.65 0.76
13 PMD 62 0.53 1.05 2.62 *
Control 31 0.03 0.18
14 PMD 62 0.81 0.96 1.94
Control 31 0.42 0.81
15 PMD 63 1.49 1.33 4.97 **
Control 31 0.26 0.10
Final score PMD 63 47.19 11.85 12.33 **
Control 31 17.81 8.46

Note: * p < 0.05; ** p < 0.001

Discussion
Sensory and perceptual-motor performance components are recognized as
important foundational skills in children that are vital for the attainment of
the abilities necessary for adequate function in all occupational performance
areas, including in their role as students (Ayres, 1979; Dunn, 1992; Hanft and
Place, 1996; Duncan, 1998). The authors’ statement of purpose in developing
the QNST–II, as a tool to be used for screening the sensory-perceptual-motor
components that underlie learning, seems to coincide with the performance
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Using the QNST–II to identify perceptual-motor deficits 193

TABLE 3: Comparison of assigned categorization scores between groups on the QNST–II

Subtest Weighted score PMD (%) Control (%) χ2

1 1 66.7 83.9 6.83 *

2 22.2 16.1
3 11.1 0
2 1 17.5 71 35.58 **
2 46 29
3 36.5 0
3 1 21.4 74.2 25.68 **
2 50 22.6
3 28.6 3.2
4 1 47.6 77.4 8.06 *
2 33.3 16.1
3 19 6.5
5 1 29 87 32.7 *
2 51 12
3 19 0
6 1 31.7 87.1 29.16 **
2 30.2 9.7
3 38.1 3.2
7 1 38 100 43.04 **
2 43 0
3 17 0
8 1 33.3 61.3 17.52 **
2 20.6 32.3
3 46 6.5
9 1 15.9 58.1 26.00 **
2 57.1 41.9
3 27 0
10 1 6.7 64.5 35.29 **
2 66.7 25.8
3 26.7 9.7
11 1 27 64.5 17.54 **
2 55.6 35.5
3 17.5 0
12 1 23.8 83.9 37.95 **
2 41.3 16.1
3 34.9 0
13 1 83.9 100 8.7 *
2 12 0
3 3 0
14 1 75.8 87.1 1.0
2 24.2 12.9
3 0 0
15 1 50.8 96.8 25.96 **
2 22.2 3.2
3 27 0
Final Score 1 3.2 83.9 65.66 **
2 58.7 16.1
3 38.1 0
Notes: * p < 0.05; ** p < 0.001
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194 Parush et al.

TABLE 4: Factor analysis item loadings

Number Subtest Factor Factor Factor Factor Factor

1 2 3 4 5

3 Palm form recognition 0.734

2 Figure recognition
and production 0.728
5 Sound patterns 0.626
10 Arm and leg extension 0.595
6 Finger to nose 0.547
9 Rapidly reversing repetitive
hand movements 0.493
13 Skip 0.874
14 Left-right discrimination 0.771
11 Tandem walk 0.703
12 Stand on one leg 0.524
7 Thumb and finger circle 0.496
1 Hand/skill writing 0.814
4 Eye tracking 0.633
15 Behavioural irregularities 0.617
8 Double simultaneous stimulation 0.709

features that occupational therapists would choose to look at to identify chil-

dren who may be at risk for school dysfunction (Hanft and Place, 1996; Mutti
et al., 1998, Dunn, 2000b; Spitzer and Roley, 2001). Therefore, the purpose of
this study was to examine the psychometric characteristics of the QNST–II
and its ability to discriminate between children with and without perceptual-
motor deficits.
Reliability must primarily be established to prevent scores of a given test
from confounding experimental outcomes. Reliability was investigated by
using three separate procedures: internal consistency, interrater reliability and
test–retest reliability. The first procedure, internal consistency, examines the
degree to which an individual test performance is consistent from item to
item. The high correlations obtained for test items of the QNST–II indicate
that the test is of a single attribute.
The second procedure determines whether an agreement exists between
raters concerning the test scores. The last procedure tests the stability of sub-
ject scores over time. Results of the interrater and test–retest reliability
procedures performed for this study suggest that scores of the QNST–II are
consistent and repeatable, and therefore can be used reliably. Our results for
interrater reliability exceeded those reported in the test manual, but were
lower for test–retest reliability. The higher interrater coefficient obtained in
our study can be explained by the fact that our examiners had extensive train-
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Using the QNST–II to identify perceptual-motor deficits 195

ing and experience. It is possible that the relatively low coefficient yielded for
test–retest reliability was influenced by intervening environmental factors,
such as the child’s or examiner’s condition or distracting stimuli in the envi-
ronment. It is also worth noting that children with perceptual-motor
difficulties often show inconsistencies in performance, a fact that often serves
to challenge our understanding of the nature of their problems (Barkley, 1991;
Mutti et al., 1998).
The primary purpose of construct validity is to examine the ability of a test
to measure the hypothesized trait of interest (Cronbach and Meehl, 1955). A
measure has construct validity if its items are representative of the content
domain being sampled. One way to determine construct validity is by testing
whether groups differ on the measured attribute (Crocker and Algina, 1986).
Another way to determine construct validity is by using factor analysis to
determine whether subtests, which are supposed to measure the same trait,
cluster together in a common factor. Both procedures were applied to deter-
mine the construct validity of the QNST–II.
The results of t-test and chi-square analysis showed that children with per-
ceptual-motor problems scored significantly higher in total scores than the
children without perceptual-motor problems. Although the QNST–II manual
suggests using the total score to identify possible problems, statistical analysis
was also conducted on each item of the QNST–II, which yielded differences
between both groups of children on all performance indices.
With regards to the chi-square analysis, examination of Table 3 shows that
a few cells representing the group of typically developing children contain few
members, if any, that can be considered problematic. However, this occurred
for the most part in the severe discrepancy cell, with only two instances in the
moderate discrepancy cell. In fact, low numbers of severe and moderate dis-
crepancy findings are to be expected among typically developing children,
which would lead one to anticipate such member distribution in the chi-
square tables. Therefore, these results can be accepted, along with the findings
that significant differences exist between the two study groups, showing that
the QNST–II is capable of distinguishing between children with and without
perceptual-motor problems. These study findings support the construct validi-
ty of the QNST–II.
The factor analysis conducted for the QNST–II obtained five factors that
may represent five different sub-areas of perceptual-motor function. The fact
that five different factors were found from among the 15 items comprising the
QNST–II serves further to emphasize the wide range of performance compo-
nents incorporated in this instrument. A review of the clusters shows that
Factor I corresponds to form recognition, Factor II corresponds to kinaesthetic
function, Factor III corresponds to motor planning, Factor IV corresponds to
visual and visual-motor functions and Factor V, which consists of only one
item, stands for tactile function. The clustering of the items into those specif-
ic factors provides further evidence that the QNST–II taps performance
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196 Parush et al.

components that are of interest in the evaluation process of occupational

therapy. The identified relationship between the item ‘behavioural irregulari-
ties’ and the other items that cluster in Factor IV has no logical explanation.
Continued research is needed to examine factor analysis on the QNST–II
with a larger sample of subjects, in order to be confident that the items cluster
in the same way as was found in our study. Further validation of the factors
identified in this study can be used when testing children in order to examine
patterns of the children’s performance.
Knowledge of a test’s sensitivity and specificity is helpful in evaluating the
ability of the test to accurately detect the target population. Sensitivity of the
test indicates the extent to which the test detects the dysfunction when it is
actually present, whereas specificity of the test indicates the extent to which
the test rules out dysfunction when it is actually absent. In our study, the pro-
portion of children correctly classified as at risk was a respectable 97%
compared with a misclassification of only 3%. These results stress the capabili-
ty of the QNST–II to identify with relatively high precision children with
difficulties in perceptual-motor abilities related to learning problems. They are
in accordance with Heslin (1981) and Sileo (1977) who, using the QNST,
correctly identified a high percentage of students with learning disabilities.
The percentage of children that fell under the category of false negative, or
that might have been under-referred or missed in our study, was extremely low.
However, it is also important to consider the likelihood of mistaken classifica-
tion of the control children and its implications. The QNST–II incorrectly
classified (false positive) 16% of the children without perceptual-motor prob-
lems. A mistaken classification can cause distress for both children and
parents. It is therefore important to clearly explain to children and their par-
ents that a referral for follow-up should be viewed as an expression of concern,
not as a definite sign that something is wrong with the child.
In conclusion, the present study represents another step in the reliability
and validation process of the QNST–II. Our findings support the use of the
QNST–II as a standardized method for testing perceptual-motor difficulties in
the screening process of identifying children at risk for school dysfunction.
When considering the practical benefit of the QNST–II, it should also be
taken into consideration that it is a test that minimizes the time needed for
administration, scoring and interpretation. In addition, the QNST–II,
although a screening test, can be categorized as a criterion-referenced mea-
surement for sensory-perceptual-motor performance components, in which
the interpretation of the child’s score involves comparing it to the pre-speci-
fied standard of performance (Rogers, 1987; Duncan, 1998). The unique
scoring system of the QNST–II differentiates between findings reflective of
developmental discrepancies (scored as 1 on the test) and those that demon-
strate more serious signs of atypical performance (scored as 3) (Mutti et al.,
1998). This system provides useful information to the occupational therapist
clinician regarding the child’s mastery of sensory and motor performance abili-
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Using the QNST–II to identify perceptual-motor deficits 197

ties, which can be used as a guideline for further testing using standardized
assessments, such as for example, the Sensory Integration and Praxis Tests
(Ayres, 1989), and to determine the direction for future intervention if need-
ed.
However, results of this study should be viewed with caution. Reliability was
conducted on small sample sizes. Construct validation is an ongoing process and
is not the only factor in establishing the validity of a test (Gottesman and
Cerullo, 1991). There is certainly a need to replicate our study with more chil-
dren with a variety of diagnoses, and to further investigate and establish
different kinds of psychometric properties, such as predictive validity. Factor
analysis should also be repeated using a larger study sample in order to verify the
clustering of the QNST–II into five factors as was found in this study.
Future research should include the examination of findings indicative of
functional performance of school children and how this correlates with the
measures yielded by the QNST–II. This could be achieved by comparing the
results of the QNST–II with the findings of an assessment that tests occupa-
tional performance of school-age children, such as the School Function
Assessment (Coster et al., 1998).

References
American Occupational Therapy Association (1989). Occupational therapy in early interven-
tion and school services: Position paper. American Journal of Occupational Therapy
43(11): 767–8.
American Occupational Therapy Association (1994). Uniform Terminology for Occupational
Therapy (3rd edition). Rockville, MD: AOTA.
Ayres AJ (1979). Sensory Integration and the Child. Los Angeles, CA: Western Psychological
Services.
Ayres AJ (1980). Southern California Sensory Integration Tests, Revised. Los Angeles, CA:
Western Psychological Services.
Ayres AJ (1989). Sensory Integration and Praxis Tests. Los Angeles, CA: Western Psychologi-
cal Services.
Barkley RA (1991). Attention deficit hyperactivity disorder. Psychiatric Annals 21: 725–33.
Baum C (2000). Occupation-based practice. Reinventing ourselves for the new millennium.
Occupational Therapy Practice (January): 12–15.
Beery KE (1989). VMI – Developmental Test of Visual-motor Integration. Administration,
Scoring and Teaching Manual. New York: Modern Curriculum Press.
Bruininks RH (1978). The Bruininks-Oseretsky Test of Motor Proficiency. Circle Pines, MN:
American Guidance Service.
Bundy A (1995). Assessment and intervention in school-based practice: Answering questions
and minimizing discrepancies. Physical and Occupational Therapy in Pediatrics 15(2):
69–86.
Chiarenza GA (1990). Motor-perceptual function in children with developmental reading dis-
orders: Neuropsychophysiological analysis. Journal of Learning Disabilities 23(6): 375–85.
Colarusso RP, Hammill DD (1996). Motor-Free Visual Perception Test – Revised (MVPT–R).
San Rafael, CA: Academic Therapy Publications.
Coster W (1998). Occupation-centered assessment of children. American Journal of Occupa-
tional Therapy 52(5): 337–44.
OTI 9(3)_3rd/crc 2/10/02 10:35 AM Page 198

198 Parush et al.

Coster WJ, Deeney T, Haltiwanger J, Haley SM (1998). The School Function Assessment:
Standardized version. Boston, MA: Boston University.
Coutinto MJ, Hunter DL (1988). Special education and occupational therapy: Making the rela-
tionship work. American Journal of Occupational Therapy 42(11): 706–12.
Crocker L, Algina J (1986). Introduction to Classical and Modern Test Theory. New York:
Holt, Rinehart & Winston.
Cronbach LJ (1970). Essentials of Psychological Testing. New York: Harper & Row.
Cronbach LJ, Meehl PE (1955). Construct validity in psychological tests. Psychological Bul-
letin 52: 281–302.
Duncan M (1998). Interpretation and application. In J Hinojosa, P Kramer (eds) Evaluation:
Obtaining and Interpreting Data. Bethesda, MD: The American Occupational Therapy
Association, pp. 145–64.
Dunn W (1992). Occupational therapy collaborative consultation in schools. In EG Jaffe,
CF Epstein (eds) Occupational Therapy Consultation: Theory, Principles and Practice.
St Louis, MI: Mosby, pp. 210–36.
Dunn W (2000a). Using frames of reference and models of practice to guide practice. In
W Dunn (ed.) Best Practice Occupational Therapy: In Community Service with Children
and Families. Thorofare, NJ: Slack, pp. 27–54.
Dunn W (2000b). The screening, pre-assessment, and referral process. In W Dunn (ed.) Best
Practice Occupational Therapy: In Community Service with Children and Families. Thoro-
fare, NJ: Slack, pp. 55–78.
Dworkin PH (1986). Educational readiness. Pediatrician 13: 62–9.
Finlayson SB, Obrzut JE (1993). Factorial structure of the Quick Neurological Screen Test –
revised for children with learning disabilities. Psychology in the Schools 30: 5–10.
Fisher AG, Murray EA (1991). Introduction to sensory integration theory. In AG Fisher, EA
Murray, AC Bundy (eds) Sensory Integration Theory and Practice. Philadelphia, PA: F. A.
Davis, pp. 3–24.
Fletcher-Flinn C, Elmes H, Strugnell D (1997). Visual-perceptual and phonological factors in
the acquisition of literacy among children with congenital developmental disorder. Devel-
opmental Medicine and Child Neurology 39(3): 158–66.
Gallagher GG (1973). Preventive intervention. Pediatric Clinics of North America 20(3):
681–93.
Geiser MC (1976). The Quick Neurological Screening Test: A study of its effectiveness when
administered by minimally trained persons. Master’s thesis, California State University, San
Jose, CA, Department of Special Education.
Giangreco MF (1995). Related services decision making: A foundational component of effec-
tive education for students with disabilities. Physical and Occupational Therapy in
Pediatrics 15(2): 47–67.
Gottesman RC, Cerullo FM (1991). Validity of a screening test for school learning problems in
a pediatric clinical setting. Journal of Pediatric Psychology 16: 327–39.
Gredler GR (1992). School readiness: Assessment and educational issues. Brandon, VT: Clini-
cal Psychology Publishing.
Hanft BE, Place PA (1996). The Consulting Therapist: A Guide for OTs and PTs in Schools.
San Antonio, TX: Therapy Skill Builders, pp. 15–33.
Haskell SH (2000). The determinants of arithmetic skills in young children: Some observa-
tions. European Child and Adolescent Psychiatry 9 (Supplement 2).
Henderson SE, Hall DMB (1982). Concomitants of clumsiness in young school children.
Developmental Medicine and Child Neurology 24: 448–60.
Heslin EG (1981). The Quick Neurological Screening Test as a discriminator between learning
disabled and normal students. Unpublished doctoral dissertation, University of Northern
Colorado, Department of Education.
OTI 9(3)_3rd/crc 2/10/02 10:35 AM Page 199

Using the QNST–II to identify perceptual-motor deficits 199

Law MC, Polatajko HJ (1987). Diagnostic tests in occupational therapy: A model for evalua-
tion. The Occupational Therapy Journal of Research 7: 111–22.
McLaughlin PJ, Wehman P (1992). Preface. In PJ McLaughlin, P Wehman (eds) Developmen-
tal Disabilities: A Handbook for Best Practices. Stoneham, MA: Butterworth-Heinemann,
pp. xiii–xvi.
Mellard E (2000). Impact of federal policy on services for children and families in early inter-
vention programs and public schools. In W Dunn (ed.) Best Practice Occupational
Therapy. Thorofare, NJ: Slack, pp. 147–56.
Murray EA, Cermak KSA, O’Brien V (1990). The relationship between form and space per-
ception, constructional abilities, and clumsiness in children. American Journal of
Occupational Therapy 44(7): 623–8.
Mutti MC, Sterling HM, Martin NA, Spalding NV (1998). QNST–II. Quick Neurological
Screening Test, 2nd Revised Edition, Manual. Novato, CA: Academic Therapy Publica-
tions.
Niehues AN, Bundy AC, Mattingly CF, Lawlor MD (1991). Making a difference. Occupation-
al therapy in public schools. Occupational Therapy Journal of Research 11: 195–209.
Parham LD (1998). The relationship of sensory integrative development to achievement in
elementary students: Four-year longitudinal patterns. Occupational Therapy Journal of
Research 18(3): 105–27.
Polatajko HJ, Law M, Miller J, Scaffer R, Macnab J (1991). The effect of a sensory integration
program on academic achievement, motor performance, and self-esteem in children identi-
fied as learning disabled: Results of a clinical trial. Occupational Therapy Journal of
Research 11: 155–76.
Rogers JC (1987). Selection of evaluation instruments. In L King-Thomas, BJ Hacker (eds) A
Therapist’s Guide to Pediatric Assessment. Boston, MA: Little, Brown, pp. 19–33.
Rosenbaum DA, Carlson RA, Gilmore RO (2001). Acquisition of intellectual and perceptual-
motor skills. Annual Review of Psychology 52: 453–70.
Rosenberg PB (1989). Perceptual-motor and attentional correlates of developmental dyscalcu-
lia. Annals of Neurology 26(2): 216–20.
Royeen CB, Marsh D (1988). Promoting occupational therapy in the schools. American Jour-
nal of Occupational Therapy 42(11): 713–17.
Sileo TW (1977). The validity of the Quick Neurological Screening Test as a screening device
to determine the presence of learning disabilities in children. Unpublished dissertation,
University of Northern Colorado, Department of Education.
Spitzer S, Roley SS (2001). Sensory integration revisited: A philosophy of practice. In
SS Roley, EI Blanche, RC Schaaf (eds) Understanding the Nature of Sensory Integration
with Diverse Populations. San Antonio, TX: Therapy Skill Builders, pp. 3–27.
Sterling HM, Sterling PJ (1977). Further experiences with the QNST. Academic Therapy 12:
487–90.
Sterling HM, Sterling PJ (1980). Neurological status versus Quick Neurological Screening Test
status in 557 subjects. Academic Therapy 15: 317–23.
Stewart KB (1996). Occupational therapy assessment in pediatrics: Purposes, process and meth-
ods of evaluation. In J Case-Smith, AS Allen, PN Pratt (eds) Occupational Therapy for
Children. St Louis, MI: Mosby-Year Book, pp. 165–99.
Summerfield BC, Michie PT (1993). Processing of tactile stimuli and implications for the read-
ing disabled. Neuropsychologia 31(9): 965–76.
Sugden DA, Chambers ME (1998). Intervention approaches and children with Developmental
Coordination Disorder. Pediatric Rehabilitation 2(4): 139–47.
Taylor HG, Hack M, Klein N, Schatschneider C (1995). Achievement in children with birth
weights less than 750 grams with normal cognitive abilities: Evidence for specific learning
disabilities. Journal of Pediatric Psychology 20(6): 703–19.
 OTI 9(3)_3rd/crc 2/10/02 10:35 AM Page 200

200 Parush et al.

Wilson EB (1998). Occupational Therapy for Children with Special Needs. London: Whurr
Publishers.
Yamahara G (1972). A reliability study of the Quick Neurological Screening Test. Master’s
thesis, California State University, Jan Jose, CA.

Address correspondence to Shula Parush, PhD, OTR, School of Occupational Therapy,

Hebrew University, PO Box 24026, Mount Scopus, Jerusalem, 91240 Israel. Email:
msshulap@pluto.huji.ac.il

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