Verification and Clarification of Patterns of Sensory
Integrative Dysfunction
KEY WORDS
 sensation disorders
 touch perception
 vestibular diseases
 visual perception
Zoe Mailloux, MA, OTR/L, FAOTA, is Executive
Director of Administration and Research, Pediatric Therapy
Network, 1815 West 213th Street, Suite 100, Torrance, CA
90501; zoem@ptnmail.org
Shelley Mulligan, PhD, OTR/L, is Chair,
Department of Occupational Therapy, University of New
Hampshire, Durham.
Susanne Smith Roley, MS, OTR/L, FAOTA, is
Director of Education and Research; Gina Geppert
Coleman, MA, OTR/L, is Executive Director of Practice
and Education; and Stefanie Bodison, OTD, OTR/L, is
Director of Clinical Education and Professional
Development, Pediatric Therapy Network, Torrance, CA.
Erna Blanche, PhD, OTR/L, FAOTA, is Associate
Professor of Clinical Practice, Division of Occupational
Science and Occupational Therapy, and Sharon
Cermak, EdD, OTR, FAOTA, is Professor, Division of
Occupational Science and Occupational Therapy, Ostrow
School of Dentistry University of Southern California,
Los Angeles.
Christianne Joy Lane, PhD, is Biostatistician, Center
for Transdisciplinary Research on Energetics and Cancer,
Keck School of Medicine, University of Southern
California, Los Angeles.
The American Journal of Occupational Therapy
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Zoe Mailloux, Shelley Mulligan, Susanne Smith Roley, Erna Blanche,
Sharon Cermak, Gina Geppert Coleman, Stefanie Bodison,
Christianne Joy Lane
Building on established relationships between the constructs of sensory integration in typical and special
needs populations, in this retrospective study we examined patterns of sensory integrative dysfunction in 273
children ages 4–9 who had received occupational therapy evaluations in two private practice settings. Test
results on the Sensory Integration and Praxis Tests, portions of the Sensory Processing Measure repre-
senting tactile overresponsiveness, and parent report of attention and activity level were included in the
analyses. Exploratory factor analysis identified patterns similar to those found in early studies by Ayres
(1965, 1966a, 1966b, 1969, 1972b, 1977, & 1989), namely Visuodyspraxia and Somatodyspraxia, Vestibular
and Proprioceptive Bilateral Integration and Sequencing, Tactile and Visual Discrimination, and Tactile
Defensiveness and Attention. Findings reinforce associations between constructs of sensory integration and
assist with understanding sensory integration disorders that may affect childhood occupation. Limitations
include the potential for subjective interpretation in factor analysis and inability to adjust measures available
in charts in a retrospective research.
Mailloux, Z., Mulligan, S., Roley, S. S., Blanche, E., Cermak, S., Coleman, G. G., et al. (2011). Verification and clarification
of patterns of sensory integrative dysfunction. American Journal of Occupational Therapy, 65, 143–151. doi:
10.5014/ajot.2011.000752
S ensory integration theory was developed by A. Jean Ayres beginning in the
late 1950s and early 1960s (Ayres, 1963, 1964). The concepts and body of
knowledge subsumed under this framework, now recognized as Ayres Sensory
Integration
(ASI), are aimed at understanding the sensory and praxis func-
tions that provide the foundation for many aspects of development, social
participation, and occupational performance. In addition to the theoretical
constructs that provide a road map for understanding normal development, ASI
includes a large body of research validating the existence of patterns of sensory
integrative dysfunction. This study was designed to clarify patterns of sensory
integration dysfunction to assist with the development and validation of a di-
agnostic typology for the disorder and to assist therapists with the interpretation
of assessment data for intervention planning.
Review of the Literature
The early formulation of ASI included the development of a set of measures
for the systematic investigation of patterns of sensory integrative function and
dysfunction. The Sensory Integration and Praxis Tests (SIPT; Ayres 1989), and
their earlier version, the Southern California Sensory Integration Tests (Ayres,
1972a), as well as measures in areas such as tactile defensiveness, hyperactivity,
distractibility, and language, were included as variables in multiple studies. A
series of factor and, later, cluster analysis studies conducted between 1963 and
1989 with samples of typically developing children, children with learning
143
 disorders, and children with suspected sensory integration
problems yielded fairly consistent patterns of sensory in-
tegrative dysfunction:
• Tactile and motor planning deficits, termed somato-
dyspraxia in the later studies (Ayres, 1965, 1966a,
1966b, 1969, 1971, 1972b, 1977, 1989);
• Visual perception and visual praxis deficits, termed
visuodyspraxia in the later studies (Ayres, 1963, 1965,
1966a, 1966b, 1969, 1972b, 1977, 1989);
• Vestibular, postural, bilateral integration, and se-
quencing deficits, given various names as knowledge
of these functions evolved and new measures were ad-
ded (Ayres, 1965, 1966b, 1969, 1971, 1972b, 1977,
1989); and
• Tactile defensiveness with hyperactivity and distracti-
bility, also known as sensory overresponsiveness (Ayres,
1964, 1965, 1966b, 1969, 1972b).
Other patterns, such as those involving language functions
or associations between two or more areas of sensory per-
ception, were found in some studies (Ayres, 1969, 1972b,
1977, 1989).
The patterns that emerged supported an understanding
of disorders in sensory integration as multidimensional.
Clarity of the associations or subtypes developed as the
measures of sensory integration functions became greater
over time. Other researchers have also contributed to the
understanding of patterns of sensory integration dysfunc-
tion. Lai, Fisher, Magalhaes, and Bundy (1996) proposed
that praxis might be a possible underlying construct for
both bilateral integration and sequencing deficits as well as
for somatodyspraxia. Mulligan (1998) conducted a large-
scale factor analysis on a sample of >10,000 children and
found patterns similar to those found in Ayres’ earlier
studies (1965, 1966a, 1966b, 1969, 1972b, 1977, 1989),
including problems with bilateral integration and se-
quencing, somatosensory deficits, visual–perceptual defi-
cits, and dyspraxia. Her study also found that although
subtypes emerged from the data, the patterns were highly
correlated with one another. Mulligan suggested that they
had a common underlying construct and reinforced the
concept of integration of multiple sensory inputs from
multiple sensory systems as being important for neuro-
logical functioning. The factor loadings found in the
studies by Mulligan (1998) and Ayres (1965, 1966a,
1966b, 1969, 1972b, 1977, 1989) also provided insight
into specific relationships among functions, such as the role
of somatosensory perception in relation to motor planning
and the relationships between vestibular, postural–ocular,
and bilateral functions.
On the basis of SIPT scores, Ayres (1989) identified
six cluster patterns that emerged from a mixed sample of
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typically developing children and children with sensory
integration problems. Three of the six cluster groupings
were thought to represent patterns not specifically asso-
ciated with sensory integration dysfunction. Two of the
groupings were characterized by sensory integration
functions in the average range (low-average and high-
average sensory integration and praxis). The third pat-
tern involved language processing (dyspraxia on verbal
command) that Ayres (1989, p. 182) suggested might
reflect left cerebral hemisphere functions rather than
sensory integration dysfunction.
The three clusters characterized by recognizable
patterns of sensory integration were Bilateral Integration
and Sequencing, Visuo-Somato Dyspraxia, and Gener-
alized Sensory Integration Dysfunction (Ayres, 1989).
Mulligan’s (2000) cluster analysis of a large data set
of children tested with the SIPT revealed that children
fell into one of five cluster groupings: average sensory
integration and praxis, moderate sensory integration dys-
function, severe sensory integration dysfunction and dys-
praxia, dyspraxia, and low-average bilateral integration and
sequencing. The results of this study suggested that in
addition to the type of dysfunction, severity of dysfunction
was an important consideration.
Other researchers (Dunn 1997, 1999; Parham &
Ecker, 2007; Miller-Kuhanek, Glennon, & Henry, 2007)
have focused more attention on patterns related to re-
sponses to sensory experiences than have previous re-
searchers. Some of these studies revealed strong associations
between various sensory patterns, again reinforcing the
interrelationships of sensory integration constructs.
The body of research by Ayres (1965, 1966a, 1966b,
1969, 1971, 1972b, 1977, 1989) and Mulligan (1996,
1998, 2000), showing consistent patterns of sensory
integration dysfunction and the strong ability of the
SIPT and its precursors to discriminate between typically
developing children and children with learning, behavior,
attention, or suspected sensory integration deficits has es-
tablished the tests’ validity. However, previous studies ex-
amining patterns of sensory integration dysfunction have
had some limitations or weaknesses. Some of the earlier
studies included variables that were measured by observa-
tion or other nonstandardized procedures. Later, in more
rigorous studies, certain measures, especially those related
to overresponsiveness to sensation (e.g., gravitational in-
security, tactile defensiveness), were omitted in Ayres’
factor analysis (1977, 1989). However, over- and under-
responsiveness to sensation have always been recognized in
practice (Parham & Mailloux, 2010) and have been studied
with both parent questionnaires and physiological
measures (Brett-Green, Miller, Schoen, & Nielson, 2010;
March/April 2011, Volume 65, Number 2
 Dunn, 1999; Parham & Ecker, 2007; McIntosh, Miller,
Shyu, & Hagerman, 1999; Parush, Sohmer, Steinberg &
Kaitz, 1997; Schaaf, Miller, Seawell, & O’Keefe, 2003;
Reynolds & Lane, 2009). Mulligan’s (1998) work used
a convenience sample from a stored database, and knowl-
edge about the characteristics of the children included in
the analysis was limited. Moreover, Mulligan’s research did
not include a measure of over- or underresponsiveness to
sensory experiences. In a an evidence review of subtypes of
problems in sensory integration, Davies and Tucker (2010)
identified the need for “comprehensive assessment of sen-
sory function and sensory-based motor performance that
includes sensory perception, discrimination, modulation,
and praxis in a single study” (p. 399).
In this study, we aimed to improve on these method-
ological challenges by examining data from a large clinical
sample in which (1) the test examiners were known to have
had extensive training in the use of the tests and in ASI theory
and its application in occupational therapy practice, (2) the
background and presenting problems of the children were
known, and (3) parent report measures regarding over-
responsiveness to sensory experiences and the presence or
absence of difficulties with attention were available in ad-
dition to SIPT scores.
Another challenge faced by researchers who have con-
ducted studies examining patterns of dysfunction using
the SIPT concerned the management of data from the
Postrotary Nystagmus (PRN) test. PRN, 1 of the 17 SIPT
components, is a measure of vestibular function. PRN is
unique in that it is the only SIPT measure in which both
a high and a low Z score are indicative of dysfunction (for
all other tests, only low scores are indicative of dysfunc-
tion). Moreover, a low PRN score is believed to be asso-
ciated with a type of problem different from a high PRN
score. This distribution of high and low scores in children
with sensory integrative challenges is suspected to have
diminished this measure’s clarity in relation to the other
measures (such as bilateral coordination and balance),
particularly when mean scores and correlation statistics
have been applied.
To verify and clarify patterns of sensory integrative
dysfunction, with consideration of previous research find-
ings and challenges regarding variables, we reexamined
associations identified in previous studies by including
comprehensive measures of sensory integration functions
(SIPT) and items from a parent report of responses to
sensory experiences and parent reports of problems with
attention. In addition, we explored methods for managing
the PRN test, which vary from those for other sensory
integration tests because both high and low scores are re-
flective of dysfunction.
The American Journal of Occupational Therapy
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Hypotheses
We hypothesized that the population under study would
demonstrate patterns of sensory integration dysfunction
similar to those found in previous studies. The specific
hypotheses were that the following associations and patterns
would emerge:
• Visual perception and visual praxis would be associ-
ated, reflecting a pattern of visuopraxis.
• Tactile perception and praxis would be associated, re-
flecting a pattern of somatopraxis.
• Vestibular functions and bilateral motor coordination
and sequencing would be associated, reflecting a pat-
tern of vestibular bilateral integration and sequencing.
• Tactile perception tests would be associated with each
other or with other sensory perception tests.
• Sensory overresponsiveness and attention would
be associated.
Method
Research Design
Four licensed occupational therapists and research assis-
tants conducted a retrospective chart review to extract data
from the charts of children who received occupational
therapy evaluations from two pediatric therapy practices
in California. The sample was extracted from the files of
425 children who had been tested with the SIPT and the
Sensory Processing Measure–Home Form (SPM–Home
Form; Parham & Ecker, 2007) or the precursor to this
instrument, the Evaluation of Sensory Processing (ESP;
Johnson-Ecker & Parham, 2000; Parham & Ecker,
2007). Deidentified scores from these measures then un-
derwent descriptive analyses and factor analysis to examine
patterns of sensory integration dysfunction. Permission to
conduct the study was obtained from the University of
New Hampshire Institutional Review Board.
The research team developed a protocol for data extrac-
tion that included the review and recording of data primarily
from the occupational therapy assessment report, assessment
forms, and intake form. Interrater reliability was established
with three members of the research team, who compared
their ratings of 20 parents’ report of their child’s attention
and activity level. The raters obtained 70% agreement on the
initial ratings. The ratings were discussed, and operational
definitions for rating attention were refined. On a second
set of 20 reports, the four raters achieved 100% agreement.
Sample
Participants < age 4 yr or > age 9 yr at the time of their
evaluation were excluded so that the sample included
145
 only those within the age range for which normative involves tactile processing simultaneously with two
data on the SIPT are available. Children whose parents hands, the two scores for this test were kept separate. The
reported coexisting neurodevelopmental or other me- PRN test has created challenges in previous studies be-
dical conditions, such as cerebral palsy, autism, Down cause both low (£–1) and high (³1) Z scores represent
syndrome, mental retardation, hearing or visual impair- dysfunction; combining high and low PRN scores results
ment, and seizure disorders, were also excluded. After age in mean scores for the group that appear average, so the
and diagnostic exclusions, we selected for analysis data research team entered this variable in several ways, in-
from 273 children who were referred for a comprehensive cluding initially entering high and low scores as separate
occupational therapy evaluation for suspected sensory in- variables. However, initial review of the data revealed that
tegration problems. only about 8% (23 of 273) of the children in the sample
demonstrated prolonged (³1.0 standard deviation) PRN.
Instruments Because the canceling effect was not present in this sam-
The variables measuring sensory integration and praxis ple, the major Z scores were entered in the same manner as
functions included in the study are summarized in Table 1 the other SIPT scores, thus resulting in a total of 18 var-
and described here. iables for the SIPT.
Sensory Integration and Praxis Tests. The SIPT is a Sensory Processing Measure–Home Form. The SPM–
battery of 17 tests measuring visual form and space per- Home Form is a parent questionnaire standardized on
ception, somatosensory functions (tactile and propriocep- children in Grades K–6. Test–retest reliability was strong
tive processing), vestibular processing (including balance), (r 5 .94; Parham & Ecker, 2007). Internal consistency of
bilateral coordination, sequencing, and praxis. The test is items yielded a coefficients >.80, and data support the
standardized on children ages 4 yr, 0 mo, to 8 yr, 11 mo. SPM–Home Form’s construct and content validity
The validity and reliability data provided in the test (Parham & Ecker, 2007). Items considered for analysis
manual (Ayres, 1989) are strong. The major Z scores for were those that targeted areas of overresponsiveness to tac-
all SIPT measures described in the test manual were in- tile, auditory, and movement experiences; vestibular and
cluded in the analysis, with the exception of the Manual proprioceptive seeking; and ocular and postural control.
Form Perception test, for which both Part 1 and Part 2 Because many of the children included in the study had
scores were entered separately. Because Part 1 involves been administered an earlier research version of the SPM,
matching tactile stimuli with visual stimuli and Part 2 the ESP, only items in these areas on both forms were
included. After preliminary analyses, we decided that the
Table 1. Means and Standard Deviations for Variables Included six items related to tactile defensiveness would be most
in Factor Analysis
useful because relatively few items were included in the
Standard other areas and tactile defensiveness was a pattern that
SIPT Data Mean Deviation
had emerged in previous studies (Ayres, 1965, 1966a,
1. Space Visualization (Z score) 20.52 0.90
1966b, 1969, 1972b). Thus, the following items (listed
2. Figure Ground 20.06 0.50
3. Standing and Walking Balance 21.20 1.07
by their accompanying SPM or ESP item number) were
4. Design Copying 20.54 1.06 included:
5. Postural Praxis 20.52 1.12 • SPM 30/ESP T4 (overresponsive): Does your child pull
6. Bilateral Motor Coordination 20.44 1.01 away from being touched lightly?
7. Praxis on Verbal Command 20.33 1.28 • SPM 32/ESP T7 (overresponsive): Does your child re-
8. Constructional Praxis 20.30 1.14
act negatively to the feel of new clothes?
9. Postrotary Nystagmus 20.50 1.09
10. Motor Accuracy 20.74 1.14
• SPM 33/ESP T16 (overresponsive): Does your child
11. Sequencing Praxis 20.62 1.06 prefer to touch rather than be touched?
12. Oral Praxis 20.91 1.15 • SPM 34/ESP T27 (overresponsive): Does it bother your
13. Manual Form Perception I 20.14 1.16 child to have his/her finger or toe nails cut?
14. Manual Form Perception II 20.23 1.22 • SPM 35/ESP T36 (overresponsive): Does it bother your
15. Kinesthesia 20.74 1.26
child to have his/her face touched?
16. Finger Identification 20.47 1.24
17. Graphesthesia 21.11 1.04
• SPM 36/ESP T12 (overresponsive): Does your child
18. Localization of Tactile Stimuli 20.78 1.28 avoid getting his/her hands in finger paint, paste, sand,
19. Tactile Defensiveness 1.40 0.71 clay, mud, glue, or other messy things?
20. Attention Behavioral Rating (rating 0–2) 0.99 0.93 The items were scored on a scale ranging from 1 to 4,
Note. SIPT 5 Sensory Integration and Praxis Tests. with a lower score indicating more difficulty, to match the

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 other variables and facilitate interpretation. The mean
score for the six ESP and SPM variables was calculated
and included in the analysis.
Behavior Rating of Attention. Because we were interested
in revisiting the existence of patterns related to over-
responsiveness to sensory experiences, we included a
behavioral measure of attention–inattention and distract-
ibility. Descriptive data from the intake form in the charts
provided a means of capturing the presence of problems
and parental concerns related to the child’s ability to attend
to tasks, activity level, and impulsiveness. A scale ranging
from 0 to 2 was used to rate attention problems provided by
parents (2 5 definite evidence, significant problem; 1 5 some
evidence, mild or potential problem; 0 5 no evidence of
problems with attention). Interrater reliability was estab-
lished on this measure using 20 cases across three raters,
who achieved 100% agreement on the ratings after re-
finement of definitions.
Data Analysis
After exploratory, descriptive data analysis, we conducted
factor analysis to examine patterns of sensory integration
dysfunction. We calculated descriptive statistics, including
frequencies, means, and standard deviations, for all var-
iables, and estimated bivariate Pearson correlation coef-
ficients between all variables (Table 2). Factor analysis
was performed using SPSS 16.0 (SPSS Inc., Chicago).
Exploratory factor analysis using principal components
extraction with varimax rotation was performed using the
variables listed in Table 1 to assist with determining the
patterns of dysfunction or domains of sensory integration
dysfunction being measured.
Results
The sample included 193 boys (70.7%) and 80 girls
(29.3%) ranging in age from 4 to 9. Most of the children
(78.1%) had no diagnosis on file and were referred for
evaluation because of occupational performance prob-
lems suspected to be the result of underlying sensory
integration dysfunction. Diagnoses or conditions that
were reported included sensory integration disorder
(n 5 29; 10.6%), attention deficit disorders (n 5 20;
7.3%), and speech–language or learning disorders (n 5
17; 6.2%).
The results of the factor analysis yielded six factors
with eigenvalues >1. However, because two factors
included only one variable, we felt that a four-factor so-
lution best fit the data, accounting for 48% of the vari-
ance. The four-factor solution with accompanying factor
loadings is shown in Figure 1. All factors in this study
were significantly related to one another (Table 3).
The first factor, named Visuodyspraxia and Somato-
dyspraxia, is characterized by high loadings on the tests of
visual perception and visuopraxis functions, including

Table 2. Pearson Correlations for Variables Included in Factor Analysis

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1. ATTN —
2. BMC .08 —
3. CPR .06 .28 —
4. DC .08 .34 .51 —
5. FG .08 2.02 .13 .10 —
6. FI .14 .21 .29 .33 .16 —
7. GRA .20 .37 .25 .35 .18 .35 —
8. KIN .07 .25 .31 .36 .07 .30 .37 —
9. LTS .10 .09 .25 .22 .10 .34 .30 .21 —
10. MAC .10 .32 .22 .46 .07 .31 .40 .33 .26 —
11. MFP 1 .07 .27 .48 .42 .14 .31 .28 .26 .16 .25 —
12. MFP 2 .05 .23 .29 .26 .02 .30 .25 .23 .16 .25 .39 —
13. OPR 2.04 .38 .15 .21 2.07 .17 .36 .17 .15 .23 .14 .15 —
14. PPR .03 .31 .29 .42 .07 .35 .25 .26 .05 .30 .33 .14 .37 —
15. PRN .04 .07 .02 .07 .04 .09 .17 .17 .00 .19 .08 .15 .10 .09 —
16. PRVC .19 .36 .36 .39 .12 .29 .34 .34 .08 .24 .32 .33 .22 .40 .14 —
17. SPR .14 .52 .38 .49 .16 .38 .48 .41 .24 .39 .36 .31 .33 .37 .19 .44 —
18. SV .21 .18 .34 .48 .16 .32 .35 .24 .17 .35 .33 .27 .14 .34 .08 .30 .41 —
19. SWB .03 .35 .29 .39 .01 .30 .36 .28 .23 .52 .21 .25 .32 .35 .22 .33 .41 .32 —
20. TD .04 2.05 2.03 .04 .00 2.07 .02 .03 2.03 2.07 2.02 .10 2.05 2.05 2.06 .03 .04 .06 .00 —
Note. ATTN 5 Attention Behavioral Rating; BMC 5 Bilateral Motor Coordination; CPR 5 Constructional Praxis; DC 5 Design Copying; FG 5 Figure Ground; FI 5
Finger Identification; GRA 5 Graphesthesia; KIN 5 Kinesthesia; LTS 5 Localization of Tactile Stimuli; MAC 5 Motor Accuracy; MFP 1 and MFP 2 5 Manual Form
Perception, Parts 1 and 2; OPR 5 Oral Praxis; PPR 5 Postural Praxis; PRN 5 Postrotary Nystagmus; PRVC 5 Praxis on Verbal Command; SPR 5 Sequencing
Praxis; SV 5 Space Visualization; SWB 5 Standing and Walking Balance; TD 5 Tactile Defensiveness.

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 Design Copy, Construction Praxis, and Space Visualization.
These three tests were all previously associated with factors
generally named Visuopraxis or Visuodyspraxia (Ayres,
1965, 1966a, 1966b, 1969, 1972b, 1977, 1989). The
presence of Postural Praxis, Praxis on Verbal Command,
and Manual Form Perception on this factor suggests a mild
association with a pattern of Somatodyspraxia. Postural
Praxis (formerly called Imitation of Postures) consistently
loaded on factors characterized by an association between
tactile perception and praxis tests in previous studies
(Ayres, 1965, 1966a, 1966b, 1969, 1972b, 1977, 1989). In
addition, Praxis on Verbal Command does not have a vi-
sual component, and the Manual Form Perception Test
involves tactile processing and visual perception. There-
fore, in relation to the patterns that were hypothesized, this
factor represents Visuodyspraxia with some secondary as-
pects of Somatodyspraxia.
The second factor, Vestibular and Proprioceptive
Bilateral Integration and Sequencing, was consistent with
the second hypothesized pattern. Many previous studies
demonstrated a bilateral integration and sequencing
pattern, associating bilateral integration with vestibular
and proprioceptive functions. This pattern was charac-
terized by high loadings on Oral Praxis, Standing and
Walking Balance, Postrotary Nystagmus, Bilateral Motor
Coordination, Graphesthesia, Motor Accuracy, and Se-
quencing Praxis. Of the tests loading on this factor, Oral
Praxis, Standing and Walking Balance, Bilateral Motor
Coordination, Graphesthesia, and Sequencing Praxis all
loaded on the Bilateral and Sequencing factor reported in
the SIPT manual (Ayres, 1989). All of these tests were
noted to involve bilateral and sequential actions. In this
study, the addition of Motor Accuracy to this group is
hypothesized to reflect the vestibular and bilateral func-
tions needed for the coordination of eye, head, and hand
movements; postural adjustments; and crossing of body
midline needed in this test. Another significant finding in
this study was the presence of the PRN test on this factor,
which had been hypothesized as an important measure of
this pattern in the past but had not loaded with similar
factors in previous work. It is likely that the distribution of
scores in this sample (relatively few children with ab-
normally high PRN scores) contributed to this finding.
Also noteworthy was that the test of Kinesthesia, as would
be expected, loaded on this factor, although modestly. The
presence of both Standing and Walking Balance and
Kinesthesia led to adding the term “proprioceptive” to the
name of this factor.

Figure 1. Primary loadings for four-factor solution.

Note. ATTN 5 Attention Behavioral Rating; BMC 5 Bilateral Motor Coordination; CPR 5 Constructional Praxis; DC 5 Design Copying; FG 5 Figure Ground; FI 5
Finger Identification; GRA 5 Graphesthesia; KIN 5 Kinesthesia; LTS 5 Localization of Tactile Stimuli; MAC 5 Motor Accuracy; MFP 1 and MFP 2 5 Manual Form
Perception, Parts 1 and 2; OPR 5 Oral Praxis; PPR 5 Postural Praxis; PRN 5 Postrotary Nystagmus; PRVC 5 Praxis on Verbal Command; SPR 5 Sequencing
Praxis; SV 5 Space Visualization; SWB 5 Standing and Walking Balance; TD 5 Tactile Defensiveness.

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 Table 3. Rotated Loadings for Final Solution praxis that she named Apraxia and Dyspraxia (later,
Factor Loading Visuodyspraxia and Somatodyspraxia). In the 1989 data
Visuodyspraxia and Somatodyspraxia from the SIPT manual, these independent patterns were
Constructional Praxis .834 notably stronger (i.e., first-order factors) in the samples
Manual Form Perception Part 1 .805 that had large numbers of typically developing children. A
Design Copying .670 cluster analysis of the same data revealed a Visuodyspraxia
Postural Praxis .510
and Somatodyspraxia cluster group that included more
Praxis on Verbal Command .498
Space Visualization .480
children with learning disabilities or sensory integration
Manual Form Perception Part 2 .437 issues (n 5 22) than children from the normative group
Vestibular and Proprioceptive Bilateral (n 513). It is possible that visuo- and somato-based
Integration and Sequencing praxis functions overlap more in samples of children with
Oral Praxis .727
identified problems, as was the case with this study’s sample.
Standing and Walking Balance .657
Postrotary Nystagmus .611
The second factor finding that is especially important
Bilateral Motor Coordination .575 for both therapists and researchers is the demonstrated link
Motor Accuracy .573 between the PRN test and the low scores on tests of vestib-
Graphesthesia .562 ular and bilateral functions. Although the relationship
Sequencing Praxis .462
of hyporesponsiveness to vestibular input, evidenced by
(Kinesthesia) (.330)
Tactile and Visual Discrimination
low PRN scores, has been hypothesized, this study marks
Localization of Tactile Stimuli .729 the first time this relationship has been supported by em-
Finger Identification .483 pirical data. The small percentage of cases with prolonged
Figure Ground Perception .497 nystagmus (8.4% [n 5 23] vs. 35.9% [n 5 98] with
Tactile Defensiveness and Attention Problems
shortened-duration nystagmus) in this sample avoided
Tactile Defensiveness .688
Attention .523
the averaging effect that occurs when both high and low
PRN scores are prevalent in a sample. Thus, these find-
Factor 1 2 3 4
ings reinforce a long-held view of the significance of low
1. Visuo- and Somatodyspraxia —
PRN scores and validate Ayres’ (1989) theoretical as-
2. Vestibular and Proprioceptive Bilateral .55 —
Integration and Sequencing sumption that bilateral integration problems and other
3. Tactile and Visual Discrimination .30 .29 — signs of vestibular inefficiencies are associated with a
4. Tactile Defensiveness and Attention Problems .13 .11 .23 — shortened duration of postrotary nystagmus. The added
Note. Parentheses indicate that the loading approaches a moderate level. factor loading of the Motor Accuracy Test (which requires
vestibular- and proprioception-related coordination of
The third factor, Tactile and Visual Discrimination, head, eye, and hand movements and crossing the body
was consistent with the third hypothesis and was charac- midline) and a moderate loading on Kinesthesia also
terized by two tests of tactile discrimination and one test of reinforce the underlying commonality of vestibular and
visual discrimination. This pattern is similar to sensory proprioceptive functions in this group. Although the hy-
system factors identified in previous work (Ayres, 1989; pothesis related to the association of low PRN with bilateral
Mulligan 1998), which revealed associations between tests and sequencing measures was supported, an association
of tactile function and tests measuring another sensory between the measures of directionality, crossing midline,
system, without the accompanying loadings of praxis, bi- and laterality with this pattern was not found. The sub-
lateral, or postural measures. scores used to measure these functions may not have had
The fourth factor, Tactile Defensiveness and Attention adequate biometric properties, or these measures may not
Problems, was consistent with the hypothesized pattern and reflect functions specific to this pattern.
with the relationship between inattention and hyperactivity The absence of the Dyspraxia on Verbal Command
and tactile defensiveness described in Ayres’ (1965, 1966a, pattern (characterized by moderately high PRN and low
1966b, 1969, 1972b) early studies. Praxis on Verbal Command in previous studies) is an ad-
ditional finding in this study that may be related to the
Discussion nature of the sample. The Ayres (1989) standardization
The importance of this study lies in the verification of study that identified this pattern, as well as Mulligan
patterns of sensory integrative dysfunction that have been (1998), most likely included more children with learning
studied for nearly 50 years. Ayres found factors related to disabilities and speech–language deficits, a group more

The American Journal of Occupational Therapy 149

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 likely to have both prolonged PRN and speech–language
problems than the sample in this study.
Finally, the hypothesized association between attention
problems and heightened sensitivity to touch rather than to
tactile discrimination and practic functions was supported
by empirical data. At this time, fully exploring the hy-
pothesis that other forms of sensory overresponsiveness
(e.g., auditory defensiveness and gravitational insecurity)
are associated with problems in attention was not possible
because the number of items representing those variables
was smaller and less specific to overresponsiveness than
the items for tactile defensiveness. Continued clarifica-
tion of the relationships between generalized sensory
overresponsiveness and specific sensory responsiveness is
still needed. Efforts to clarify underlying physiological
functions associated with over- and underresponsiveness
will also provide insight into the impact of these problems
on behavior, learning, and participation (Reynolds & Lane,
2009). The significant relationship between the factors in
this study and Ayres’ (1989) studies reinforces the long-
held idea that the patterns revealed in these studies show
specific associations among sensory, motor, and praxis;
these associations reflect that sensory systems function in
a synergistic, rather than isolated, way.
Identifying and understanding underlying problems
that affect health, performance, and participation are im-
portant first steps for practice and research in occupational
therapy. The results of this study confirm the presence of
sensory integration patterns of dysfunction in children
commonly referred for an occupational therapy evaluation.
Knowledge of these patterns allows therapists to understand
the nature of difficulties interfering with performance, con-
tributes to more precise intervention planning, and pro-
vides a means by which to determine the interventions’
effectiveness. Using standardized assessments, such as the
SIPT, in conjunction with caregiver reports will enhance
participant selection in efficacy studies of occupational ther-
apy applying a sensory integrative intervention approach.
Limitations
This study’s limitations include the subjectivity of factor-
analytic studies, the subjectivity of the tools used to mea-
sure attention and tactile overresponsiveness, and the
degree of representation in the sample. First, as with all
factor analysis, the interpretation of the factors has a level
of subjectivity (e.g., the decision to use the four-factor
solution and the naming of the factors). However, given
the breadth of previous studies on which to base decisions
and the many researchers who collaborated throughout
the interpretation process, subjectivity was minimized.
150
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Second, the methods for measuring attention and tactile
overresponsiveness in this study do not have established
reliability and validity data; however, other means for as-
sessing these variables were not available in this retrospec-
tive sample. Finally, data were retrieved from only two
private practices and may therefore have limitations in gen-
eralizability. However, the similarity with previous findings
and hypothesized constructs reduces this potential concern.
Future Research
Future research should continue to identify and enhance
our understanding of the underlying neurodevelopmental
problems that affect health, performance, and participa-
tion. Measures for children younger and older than the
range included in the SIPT normative sample are needed to
determine whether these patterns of dysfunction hold true
for these age groups and are also needed to conduct out-
come studies. To conduct outcome studies, changes in
sensory integration and praxis functions must correlate
with needed and desired changes in health, performance,
and participation of the child with identified sensory in-
tegration and praxis difficulties, the family, and commu-
nity. Although this study confirmed and clarified the
presence of various subtypes of sensory integrative dys-
function, current assessment tools are still limited in several
areas, including aspects of vestibular and proprioceptive
processing, postural ocular control, and ideational praxis.
Validity studies are also needed to enhance our under-
standing of low- and high-duration PRN. Finally, future
research that includes confirmatory factor analysis of the
model with a new data set to determine whether the model
holds true is suggested.
Conclusion
ASI is one of the most developed and distinctive frames of
reference to emanate from the profession of occupational
therapy. Occupational therapists with specialized knowl-
edge of ASI have a unique understanding of the ways
in which functions such as vestibular processing, tactile
perception, and praxis contribute to daily life participation
and success. Understanding the different patterns of sen-
sory integration dysfunction allows occupational therapists
to be better equipped to design, implement, and study
intervention programs to alleviate challenges and, ulti-
mately, to support occupational performance. s
Acknowledgments
This study was supported by donations contributed by
participants at the annual R2K research conferences hosted
by Pediatric Therapy Network. We thank Allison McGuire
Young, Kacey MacManus, A. Brooks Roley, Katie Meyer,
March/April 2011, Volume 65, Number 2
 and Summer Kendricks for their assistance with data entry
and project coordination.
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