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Modification of the Postrotary Nystagmus Test for Evaluating Young Children

Article  in  The American journal of occupational therapy.: official publication of the American Occupational Therapy Association · September 2014
DOI: 10.5014/ajot.2014.011031 · Source: PubMed

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 Modification of the Postrotary Nystagmus Test for
Evaluating Young Children
MeSH TERMS
 early diagnosis
 motor skills disorders
 nystagmus, physiologic
 sensation disorders
 vestibular function tests
Zoe Mailloux, OTD, OTR/L, FAOTA, is Adjunct
Associate Professor, Department of Occupational Therapy,
Jefferson School of Health Professions, Thomas Jefferson
University, and Professional and Program Development
Consultant, 407 Camino de Encanto, Redondo Beach, CA
90277; zoemailloux@gmail.com
Marco Leão is Private Practitioner and Vice President,
.
7Senses, Integração Sensorial, Porto, Portugal.
Tracy Ann Becerra, PhD, MPH, OTR/L, is Research
Associate, Department of Research and Evaluation, Kaiser
Permanente Southern California, Redondo Beach, CA.
Annie Baltazar Mori, OTD, OTR/L, is Private
Practitioner and Owner, PlaySense Therapy, Torrance, CA.
Elisabeth Soechting, MA, OTR/L, is Private
Practitioner and Owner, SPIELSTUDIO Kindertherapie,
Vienna, Austria, and PhD Candidate, Faculty of
Psychology, University of Vienna.
Susanne Smith Roley, OTD, OTR/L, FAOTA, is
Adjunct Clinical Faculty, Division of Occupational Science
and Occupational Therapy, University of Southern
California (USC), Los Angeles.
Nicole Buss, OTD, OTR/L, is Private Practitioner, Palos
Verdes, CA.
Sharon A. Cermak, EdD, OTR/L, FAOTA, is Professor
of Occupational Science and Occupational Therapy,
Division of Occupational Science and Occupational
Therapy, USC, and Professor of Pediatrics, USC Keck
School of Medicine, Los Angeles, CA.
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Zoe Mailloux, Marco Leão, Tracy Ann Becerra, Annie Baltazar Mori,
Elisabeth Soechting, Susanne Smith Roley, Nicole Buss,
Sharon A. Cermak
This article explores the use of the postrotary nystagmus (PRN) test for children younger than current norms
(children 4.0 yr–8.11 yr). In the first study, 37 children ages 4–9 yr were examined in the standard testing
position and in an adult-held adapted position to determine whether holding a child affected the reflex.
Because the position did not affect the reflex, in the second study, PRN in 44 children ages 2 mo–47 mo
was compared with published normative mean raw scores for 44 children age 5 yr to determine whether
norms for older children were applicable to younger children. No statistically significant differences were
found between <4-yr-old and 5-yr-old children, suggesting that the PRN test can be used in infants and
toddlers with valid comparison to current norms for 4-yr-olds on the Sensory Integration and Praxis Tests
(4.0 yr–8.11 yr). Future research exploring the predictive value of this measure is warranted.
Mailloux, Z., Leão, M., Becerra, T. A., Mori, A. B., Soechting, E., Roley, S. S., . . . Cermak, S. A. (2014). Modification
of the postrotary nystagmus test for evaluating young children. American Journal of Occupational Therapy, 68,
514–521. http://dx.doi.org/10.5014/ajot.2014.011031
T he importance of early screening, assessment, and intervention planning is
crucial in all educational and health-related fields, including occupational
therapy. This focus on prevention and early intervention affords the opportunity
to identify and intervene as soon as possible to ensure optimal lifelong occu-
pational performance. Early intervention (EI) services provided to children from
birth to age 3 yr, especially for those who are at risk for or identified with
a developmental delay, usually consist of educational, therapeutic, and social
services aimed at minimizing negative and supporting positive effects on de-
velopment (American Occupational Therapy Association [AOTA], 2010).
However, even with increasing awareness of and emphasis on EI services, many
children, especially those with more subtle conditions or from families with
limited resources, are not identified with developmental or learning concerns
until they become disruptive to the family, teacher, or other caregivers. In-
cluded among the more subtle problems that can occur in early development
are irregularities in sensory perception, sensory regulation, and motor skills,
collectively known as sensory integration dysfunction (Ayres, 2005). Many types
of sensory integration difficulties are associated with problems in attention,
learning, and behavior (Mailloux et al., 2011; Parham & Mailloux, 2010) and
are often observed in people with additional diagnoses such as autism and at-
tention deficit hyperactivity disorder (Baranek, Roberts, et al., 2008; Baranek,
Wakeford, & David, 2008; Mailloux & Smith Roley, 2010; Miller et al.,
1999). Because children with underlying sensory and motor irregularities
are not easy to identify without specific testing or specialized professional
training (Bodison & Mailloux, 2006), these challenges can easily be missed
or misinterpreted.
September/October 2014, Volume 68, Number 5
 Despite increasing research showing the benefits of
early identification and intervention (Karoly, Kilburn, &
Cannon, 2009), economic and budgetary challenges in
the United States, as well as in other countries, have
limited the programs and services for families of children
at risk for developmental problems (Johnson, Oliff, &
Williams, 2011), especially those without a clear medical
diagnosis. Identifying methods for early assessment of
sensory integration functions has been a challenge for
occupational therapy practitioners and researchers because
of the limited availability of standardized assessments in
this area for infants and toddlers (Williamson, Anzalone,
& Hanft, 2000). Therefore, the purpose of this study was
to explore the use of the postrotary nystagmus (PRN) test
for infants and young children ages 2 mo–47 mo. The
PRN test, currently standardized on children ages 4.0–
8.11 yr (Ayres, 2004), provides a noninvasive, quick,
and easy-to-use assessment of the vestibular–ocular
reflex (VOR) that provides insight into sensory and motor
irregularities.
Literature Review
Mulligan (2010) noted that few easily administered and
standardized evaluation tools are available for assessing
vestibular function in children overall, and almost none
are available for infants and toddlers. Therefore, thera-
pists rely on clinical observations of a child’s gross motor
performance to make inferences about vestibular func-
tioning. Given the importance of the vestibular system in
early development (Angelaki, Klier, & Snyder, 2009), an
attempt to assess its function at as early an age as possible
is prudent. One of the most common ways to evaluate the
integrity of the vestibular system and its components is to
test the VOR, a three-neuron arc reflex from the vestibular
nucleus to the oculomotor nuclei that was first described
by Lorente de Nó in 1933 (Cohen & Raphan, 2004;
Gonçalves, Felipe, & Lima, 2008; Highstein, Popper, &
Fay, 2004). Rotational and translational head movements
stimulate the VOR, which responds with an eye move-
ment that is opposite to head movement direction (Amin
& Konrad, 2008; Highstein et al., 2004). The three
common tests used to measure the VOR are electro-
nystagmography (Barber & Stockwell, 1980; Ganança,
Caovilla, & Ganança, 2010), caloric testing (Zajonc &
Roland, 2005), and the rotational chair (Fife et al.,
2000). The rotational chair paradigm was introduced as
early as 1907 by the Austro-Hungarian otologist and
Nobel Prize winner Robert Barany (Kingma, 2009) and
served as a basis for the Southern California Postrotary
Nystagmus Tests (SCPNT) as originally published by
The American Journal of Occupational Therapy
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Ayres (1975). This test, originally published individually
and standardized for children ages 5–9 yr, is now 1 of 17
tests included as part of the Sensory Integration and
Praxis Tests (SIPT; Ayres, 2004), which is designed to
assess sensory integration and praxis functions in children
ages 4–8.11 yr (Ayres, 2004).
The PRN test evaluates the integrity of the VOR after
rotation of the head in space (Ayres, 2004). This reflex
reflects the role of the vestibular system in ocular mech-
anisms. One important function resulting from this re-
lationship is the vestibular system’s role in stabilizing the
eye muscles in response to head movements, which allows
maintenance of a stable visual field when the head is
moving. The VOR allows for the eyes to turn in the
opposite direction of head movement to preserve visual
field stability and object fixation (Lundy-Ekman, 2008).
This important neurological relationship assists in main-
taining orientation in space while navigating through the
world and in daily tasks such as eye tracking when looking
up and down, for example, in an activity such as copying
something from a whiteboard to a notebook.
Critical to human function, the vestibular sensory
system (Highstein et al., 2004) includes separate sensory
organs that perceive the basic attributes of movement
(i.e., angular and linear acceleration, angular and linear
velocity, and position with regard to gravity). Evolving
and continued research has led to the development of
new tools, techniques, and concepts for revealing more
about the role of the vestibular system’s importance in the
development and functions of balance, awareness of head
position in relation to gravity, ocular stabilization (mainte-
nance of a stable visual field when the head moves), postural
adjustments, and autonomic nervous system functions
(Highstein et al., 2004; Lundy-Ekman, 2008).
Successful active engagement in most daily life ac-
tivities requires intact vestibular system functions such as
coordination of head and eye movements, adequate
postural control, balance and postural awareness, and
coordination of the two sides of the body (Ayres, 1972,
2005; Parham & Mailloux, 2010). These body functions
provide the basis for coordinated movement and allow
children to explore, play, develop fine and gross motor
skills, and move efficiently in their multiple environments
in their daily lives (Mulligan, 2010). Therefore, vestibular
functioning, measured in part through the assessment of
PRN, is important in the evaluation of children who are
at risk for neurodevelopmental, learning, or behavioral
difficulties (Mulligan, 2010).
Both shortened and prolonged duration of PRN, in
comparison with normative data, are associated with
learning and developmental concerns (Ayres, 2004).
515
 Studies in the United States, Australia, and South
America have suggested that at least 50% of all children
with learning or language problems show signs of ves-
tibular dysfunction, indicated by an atypically shortened
duration of PRN (Ayres, 2005). In a case report study,
Ayres and Mailloux (1981) found a relationship between
expressive language and vestibular processing and, later,
another pattern characterized by prolonged-duration
PRN and language-related test scores was also reported by
Ayres (2004). Ayres (1965, 1966a, 1966b, 1969, 1972,
1977, 2004) repeatedly demonstrated patterns of difficulties
in postural, ocular, bilateral integration, and sequencing
functions that she hypothesized were associated with
vestibular dysfunction, and current research by Mailloux
et al. (2011) verified that shortened-duration PRN is, in
fact, associated with a pattern characterized by bilateral
integration and sequencing. Vestibular processing prob-
lems are also commonly reported in children with other
conditions, such as developmental coordination disorder
(Mulligan, 2010; Przysucha, Taylor, & Weber, 2008), autism
(Mailloux, 2001), attention disorders (Mulligan, 1996),
hearing impairment (Valente & McCaslin, 2011), and
learning disorders (Ayres, 1978; Mulligan, 2010). These
findings suggest that healthy vestibular function is im-
portant in meeting the demands of schoolwork and other
life tasks and that it is vital to assess vestibular functions
in children because of the incidence of problems in this
sensory system among children who are struggling in
various aspects of childhood occupations (Ayres, 2005).
Scope of the Project
We conducted two clinical studies to explore the adap-
tation and use of the PRN test for children younger than
age 4 yr as a possible screening tool for early signs of
vestibular-based sensory dysfunction. This measurement
may provide one way in which to address the need for early
and easy measures that identify salient developmental
concerns for the purpose of ensuring EI and prevention of
later disabilities. This project was based on retrospective
de-identified chart review and, as such, received University
of Southern California institutional review board approval
as an exempt study.
Clinical Study 1: Effect of Adapting the
Child’s Sitting Position on the Postrotary
Nystagmus Reflex
To explore the feasibility of adapting the PRN test for
children younger than age 4 yr, it was first necessary to
determine whether holding the child during rotation
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would have an effect on the PRN reflex. This positioning
change is critical for testing younger children who are not
able to sit and maintain the correct position. Specifically,
this project aimed to examine whether there is a difference
in duration of PRN as a function of whether the child sits
independently on the PRN board or whether the child is
held on a larger board by the child’s parent or therapist.
The adaptation includes using a larger rotary board (the
standardized board is approximately 1 ft · 1 ft square,
whereas the adapted board is approximately 2 ft · 2 ft
square) with an adult sitting on the board and holding
the child in place. This adapted administration of the
PRN test was previously used by Ayres in clinical prac-
tice, as well as by subsequent practitioners, because some
children, even within the standardized age group, were
unable to remain in the required position for testing.
However, the potential effect of this change on PRN
duration has not been formally studied.
Method
Participants. Study participants were 37 children ages
4–9 yr. The group tested included children who had
diagnoses such as autism and learning disabilities as well
as those who were receiving occupational therapy. Also
tested were their typically developing peers and siblings
who accompanied them to therapy sessions.
Procedures. Duration of PRN was tested in both
standard (C1) and adult-held (C2) administrations. Each
child was tested in both conditions (C1 and C2) with
a random assignment to C1 or C2 administered first.
Data Analysis. The differences between C1 and C2
PRN durations were computed using a two-tailed paired
Student’s t test. Significant differences between C1 and
C2 were determined at p < .05.
Results
A two-tailed t test indicated no significant differences
between the duration of PRN in the standard in-
dependent position (C1) and the adult-held position
(C2) for both clockwise and counterclockwise rotations
(see Table 1).
Discussion
The results of this study indicate that there is not a sig-
nificant difference in duration of PRN as a function of
whether the child is sitting independently or is held in the
lap of an adult. This finding indicates that either position
may be used to assess the duration of the PRN reflex and
supports clinical practice that has used this method to
assess PRN in children unable to maintain the standard,
September/October 2014, Volume 68, Number 5
 Table 1. Comparison of Standard Independent Seated Position and Adult-Held Seated Position
Independent Sitting (C1), s,
Comparison Mean (SD)
C1 vs. C2 (clockwise) 5.27 (6.70)
C1 vs. C2 (counterclockwise) 4.79 (5.52)
Note. p value presented for 2-tailed t test. Significant differences determined at p < .05. C1 5 standard administration; C2 5 adult-held administration; s 5
seconds; SD 5 standard deviation.
independent sitting position. In addition, this adaptation
may result in more reliable results for children who have
difficulty following standard test procedures, such as those
with poor postural control or those who have difficulty
following the directions for maintaining head position.
Clinical Study 2: Determining Feasibility
Using the Postrotary Nystagmus Test With
Infants and Toddlers
This study examined the three following questions:
1. Is it feasible to implement the PRN test for children
younger than age 4?
2. Will parents and children accept administration of the
PRN test with children younger than age 4?
3. Will the duration of the PRN reflex for children youn-
ger than age 4 be different from that in normative data
for children age 5?
Method
Participants. Study participants were 44 typically de-
veloping children younger than age 4 yr (23 girls and 21
boys, ages 2–47 mo). Of the 44 children, 15 were par-
ticipating in an Early Head Start program for typically
developing, low-income children and families. Testing
PRN in this group was part of regular program proce-
dures exploring potential assessments for pretest and
posttest measures to monitor and track the children’s
development, risk for delays, and response to participa-
tion in the program. Scores for these children were
identified by reviewing Early Head Start program records
to identify children who had been administered the PRN
as part of routine practice. The remaining 29 children
were typically developing infants and toddlers who were
participating in community programs or were children of
therapists or their friends who participated in practice
sessions conducted in preparation for developing clinical
application of this test for younger children. De-
velopmental delays were determined to be an exclusion
criterion; however, none of the records for the children
indicated any concerns or delays and, as such, we made
no exclusions for the records reviewed and included in
this exempt study.
The American Journal of Occupational Therapy
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Adult-Held Sitting (C2), s, Difference (C1 2 C2), s,
Mean (SD) Mean (SD) t(36), (p)
6.30 (6.02) 21.03 (4.28) 21.46 (.15)
5.83 (6.23) 21.06 (4.58) 21.38 (.18)
Procedures. The test was adapted with the children sitting
on the lap of an adult and being held in the proper position on
a larger board. The children’s heads were positioned by the
examiner in 30˚ of forward flexion as indicated in the stan-
dardized administration for the PRN test. The child’s head
position was maintained by the person holding the child. The
duration of the children’s PRN was recorded after two sep-
arate administrations of 10 rotations in 20 s (the first 10
rotations in a counterclockwise direction in 20 s and the
second 10 rotations in a clockwise direction in 20 s) in
accordance with the standardized procedures of PRN admin-
istration (Ayres, 2004). At the conclusion of each rotation, the
person holding the child lifted the child’s head to a neutral
position while the examiner observed the PRN response.
For all participants, the procedure was explained to each
parent or caregiver, all of whom expressed interest in and
willingness to have their child tested. The parents and care-
givers who felt they could tolerate being rotated on the board
while holding their child did so (n 5 14), and for those who
did not feel they would be able to tolerate the movement
themselves, an occupational therapist held the child during
the test (n 5 30). The children’s and parents’ responses to the
testing were noted during and after each test administration.
We used the SCPNT (Ayres, 1975), the precursor to
the PRN test now published as part of the SIPT, because
it reports mean group scores in number of seconds of
duration for this reflex (with standard deviations). The
tests of the SIPT are computer scored, and the means and
standard deviations for the tests were not available in the
manual (Ayres, 2004). Although the SIPT and the tests
that were precursors to it were standardized on children
ages 4.0–8.11 yr, the SCPNT was standardized on chil-
dren 5.0 yr–8.11 yr. All the other skill-based tests of the
SIPT show an age progression, with older children per-
forming better than younger children. However, the PRN
test as a reflex measure shows a flat age trend such that no
variation in the reflex response is seen in the normative
data for children ages 4.0 yr–8.11 yr. Similarly, the mean
number of seconds of duration of PRN (and standard
deviations) reported in the SCPNT manual were very sim-
ilar across the 5–9 yr age range and also between boys and
girls. Therefore, we determined that comparing the PRN
scores of the youngest norm group in the SCPNT manual
517
 (Ayres, 1975)—that is, 44 children age 5 yr—with those of
the current project sample of 44 children ages 2–37 mo
would be a reasonable process for the initial comparison of
infants and toddlers with older children on this measure.
Data Analysis. The first two research questions re-
garding the feasibility of using the PRN test with younger
children were answered by reviewing the children’s and
parents’ responses to the testing. The third question was
addressed through comparison of infants’ and toddlers’
responses on the PRN test with the available published
normative means and standard deviations for older chil-
dren. We analyzed PRN duration, recorded after rotation
in both directions (clockwise and counterclockwise), us-
ing Student’s t test for comparing two independent
samples, that is, a comparison of 44 typically developing
infants and toddlers (ages 2–47 mo) with the 44 children
(age 5 yr) whose group mean scores were published in the
SCPNT manual (Ayres, 1975). We explored whether
a correlation existed between infant and toddler age and
duration of PRN using Pearson’s correlation coefficient
and examined age trends using linear regression.
Results
Research Question 1. Once we determined that holding
a child in position did not significantly alter the PRN
response, it was necessary to determine whether it would
be feasible to hold infants and toddlers and view the PRN
reflex. Initially, the adults sat in an office chair to de-
termine whether holding an infant in their laps on this
type of chair would be a comfortable and stable way to
administer the test. However, the reduced adult hip flexion
when the adult was seated in a chair compared with when
the adult was seated on a rotational board resulted in a less
defined lap, which made holding the infant or toddler and
keeping the child’s head in 30˚ of forward flexion while
being rotated more difficult. Therefore, we determined
that the rotational board was the preferred choice. Another
consideration was whether the adults would be able to
tolerate the movement themselves. Some of the parents
and caregivers did have difficulty with this because of the
common intolerance of the rotatory stimuli among adults,
and a few parents did not find sitting on a board very
Table 2. t-Test Comparison of PRN Duration (in Seconds) Between Children Age <4 Yr and Children Age 5 Yr
Boys
Direction of Rotation <4 Yr 5 Yr t(48) (p)
N 21 29
Counterclockwise, s, mean (SD) 8.6 (2.9) 8.8 (4.2) 0.20 (0.84)
Clockwise, s, mean (SD) 9.0 (2.4) 8.9 (3.9) 0.11 (0.91)
Counterclockwise 1 clockwise, s, mean (SD) 17.6 (4.7) 17.7 (7.2) 0.06 (0.95) 19.2 (5.2) 17.3 (5.0) 1.13 (0.27) 18.4 (5.0) 17.6 (6.5) 0.65 (0.52)
Note. p value presented for two-tailed t test. Significant differences determined at p < .05. PRN 5 postrotary nystagmus; s 5 seconds; SD 5 standard deviation.
518
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comfortable for their physical size. However, some parents
(approximately 30%) were able to tolerate the rotations.
The alternative solution of having a therapist, other adult,
or older sibling who could tolerate movement hold the
child remedied this issue for those parents who could not.
Although a few children (5 of 44) cried while being
positioned on the board, all but 1 child stopped crying when
the rotation of the board began. The adults were able to hold
the child in place and lift the child’s head on stopping so the
reflex could be observed. The children did not close their
eyes; thus, administration of the PRN test and observation of
the reflex using this method was determined to be feasible.
Research Question 2. An initial concern was whether the
parents and caregivers would understand the usefulness or
meaning of the PRN test and its relevance to their child’s
development. However, the parents appeared to make easy
comparisons between the explanation of the vestibular sys-
tem and its role in early development and their children’s
behavior in daily life activities. Comments such as “Yes, he
really likes movement” were frequent, with an occasional
comment such as “She is not very comfortable with swings.”
All the parents expressed that they were comfortable with
the procedure, which took <1 min, and seemed to feel it
was safe for their children, even when some of the children
cried while being positioned. The children were able to
tolerate the test and had no adverse effects such as vomiting,
nausea, or change in state of alertness. The most significant
issue was initial hesitation to being held by one of the test
administrators instead of their caregiver. However, in al-
most every instance, the children stopped crying once the
rotation was initiated; in most cases, the children appeared
to enjoy the movement. Thus, the procedure appeared ac-
ceptable to both parents and young children.
Research Question 3. We found no significant differences
in PRN duration between infants and toddlers in comparison
with the SCPNT norms for either boys or girls (boys1girls:
counterclockwise PRN, p 5 .78; clockwise PRN, p 5 .38;
counterclockwise 1 clockwise PRN, p 5 .52) (Table 2).
Within our sample, we also found no significant differences
in PRN duration between boys and girls (counterclockwise
PRN, p 5 .35; clockwise PRN, p 5 .37; counterclockwise 1
clockwise PRN, p 5 .29). However, we found a low but
Girls Boys 1 Girls
<4 Yr 5 Yr t(36) (p) <4 Yr 5 Yr t(86) (p)
23 15 44 44
9.5 (3.4) 9.0 (2.2) 0.55 (0.55) 9.1 (3.2) 8.9 (3.6) 0.27 (0.78)
9.7 (2.7) 8.3 (3.3) 1.37 (0.18) 9.3 (2.5) 8.7 (3.7) 0.89 (0.38)
September/October 2014, Volume 68, Number 5

Figure 1. Scatterplot to test linear trend of age in months and
postrotary nystagmus (PRN) duration (clockwise 1 counterclock-
wise). For every month increase in age, combined duration of PRN
decreased by approximately 0.14 s (b 5 20.1355).
significant correlation, r (42) 5 2.34, p 5 .02, and a
negative relationship between child’s age in months and
combined duration of PRN, such that for every month
increase in age between 2 and 47 mo, combined duration
of PRN decreased by approximately 0.14 s (b 5 20.14,
p 5 .02; see Figure 1).
We found significant differences between the £17-mo
age group and the 18- to 47-mo age group (counter-
clockwise 1 clockwise, p 5 .03) and also a natural age
cutoff to separate walkers from non- or early walkers
(Capute, Shapiro, Palmer, Ross, & Wachtel, 1985;
Group & de Onis, 2006). When we separated these two
age groups, we found weaker correlations, r (17) 5 2.20,
p 5 .41, and r (23) 5 2.13, p 5 .54, respectively, and the
linear relationship between child’s age and duration of PRN
almost disappeared (b5 20.16, p 5 .41, and b 5 20.08,
p 5 .53; respectively; see Figure 2). However, larger studies
would need to confirm this finding.
Discussion
Determination of validity of adapting the PRN test to ac-
commodate children who cannot sit independently was of
interest because this method of altering the original test has
Figure 2. Scatterplot to test linear trend of age in months and postrotary nystagmus (PRN) duration (clockwise 1 counterclockwise), by two
separate age ranges. For children younger than 18 mo, for every month increase in age, combined duration of PRN decreased by approximately
0.16 s (A); for children ages 18–47 mo, for every month increase in age, combined duration of PRN decreased by approximately 0.08 s (B).
The American Journal of Occupational Therapy
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been used clinically for many years. Affirming that this ad-
aptation has no effect on PRN duration is a useful validation
of a common clinical practice. The comparison of PRN
between children ages 2–47 mo with older norms published
in the SCPNT manual (Ayres, 1975) was of interest on
several accounts. The fact that we found no significant dif-
ferences between the younger children and the published
norms in the SCPNT for 5-yr-olds suggests that the current
SIPT norms can be used as a comparative sample for chil-
dren who are younger. This information is useful in light of
the current absence of normative data on PRN for children
younger than age 4 yr. Closer inspection of the data re-
vealing some evidence of a relationship between child’s age
and nystagmus duration in the 2- to 47-mo age range was
also noteworthy. It is possible that slightly higher PRN
scores are found among young infants (0–17 mo) than
among children ages 18 mo or older, although the sample
size in this study was too small to make the comparison.
Although both shortened and prolonged PRN scores (i.e.,
less than or greater than 1.0 standard deviation from the
mean) have been associated with patterns of sensory in-
tegration problems in children older than age 4 yr, in-
terpretation of these findings in young children warrants
further study. Validity studies examining the predictive and
discriminatory ability of this test in infants and toddlers will
be particularly useful. However, the overall results of this
study do suggest that this test can be used with children
younger than age 4 with valid comparison with the current
published norms for the 4.0- to 8.11-yr age group. With
children of any age, the PRN test is meant to be considered
within the context of comprehensive assessment and is not
used as a singular determinant of function or dysfunction.
Implications for Occupational
Therapy Practice
Because early assessment is a critical first step toward EI,
identification of sensitive, reliable, and valid tools is an
519
 important consideration for pediatric occupational
therapists serving young children and their families.
The PRN test has been a simple, quick, and low-cost
means of testing one aspect of vestibular functioning as
a part of occupational therapy assessments for children
for nearly 4 decades. Occupational therapists with
advanced training in evaluation of and intervention for
sensory integrative concerns have grappled with the
means to provide similar comprehensive assessments for
younger children. The results of this project suggest
the following implications for occupational therapy
practice:
• The PRN test can be validly adapted with an adult
holding the child for the purpose of testing young
children and older children who cannot maintain the
required testing position independently.
• The PRN test can be appropriately used with children
younger than age 4 (with comparison with the current
4-yr norms) as part of other developmental and sen-
sory integration evaluations.
Conclusion and Recommendations for
Future Program Evaluation and Research
Quick and easy early screening tools predictive of de-
velopmental concerns are needed by health care providers
to ensure early identification and intervention services
for families of children with developmental concerns.
Observations such as head lag have been shown to be
salient in identifying developmental concerns, including
a later diagnosis of autism (Flanagan, Landa, Bhat, &
Bauman, 2012). Supplementing these observations with
an objective measure of neurological integrity, such as
a labyrinthine response as measured by the PRN test, will
inform the understanding of sensory integration in early
development by occupational therapy practitioners who
work with young children. Given the importance of the
vestibular system in early development, consideration of
the PRN test for infants and toddlers seems well worth
further study. Studies that examine the ability of the PRN
test to discriminate typical from atypical development
and occupational performance in young children will be
especially important. Examination of the possibility of
predicting future performance from results of this early
reflex testing will also be useful. Because both shortened
and prolonged duration of PRN are associated with dif-
ferent types of concerns in children ages 4–8 yr (Ayres,
2004; Mailloux et al., 2011), it will also be interesting to
explore ways of examining whether similar patterns can
be identified at younger ages. s
520
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Acknowledgments
We thank the following people for their assistance with de-
identified chart review and project coordination: Angee
Dowdy, Gina Coleman, Joaquim Faias, Paulo Fernandes,
Shay McAtee, Aja Roley, Mary Singer, Kerstin Starzer,
and Maria Joao Trigueiro. Portions of this project were
completed in partial fulfillment of advanced study re-
quirements for Marco Leão at the Escola Superior de
Tecnologia da Saude do Porto, Porto, Portugal.
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