Visual Perceptual Assessment

1. Visual Perceptual Assessment OCT 1172 February 1, 2005 Gianna Knibbs Shannon McCready Jeffrey Mills Melissa Peressotti

2. Presentation Outline Description of Perception & Approaches/Theories of Perception Motor-Free Visual Perceptual Assessment (MVPT) General features and application to theories Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) General features and application to theories Comparison chart of psychometrics (LOTCA, MVPT) Two practical applications

3. Definitions Perception “The dynamic process of receiving the environment through sensory impulses and translating those impulses into meaning based on a previously developed understanding of that environment” (Bouska et al., 1990)

4. Definitions (2) Visual Perception “ability to identity, organize, interpret and comprehend visual information received by a person through his or her eyes” 

5. Approaches to Understanding Perception Bottom-Up Processing Primary perceptual processes convert sensation into perception Assessment and treatment approached by evaluating individual domains of function Top-Down Processing Our learned experiences narrow possible interpretations of the sensory stimuli in the environment Assessment and treatment through observation of a person engaging in function Bottom-Up Processing: Where primary perceptual processes convert sensation into perception.W/ b-u, Ax & Tx is approached by evaluating individual domains of function: ie. figure-ground, spatial relationships, visual closure, (which will be explored in more detail when we look at each Ax). Top-Down Processing: The process by which our experiences function to narrow the possible interpretations of the sensory stimuli in the environment. Here, Ax & Tx are done through observation of a person engaging in function. Bottom-Up Processing: Where primary perceptual processes convert sensation into perception.W/ b-u, Ax & Tx is approached by evaluating individual domains of function: ie. figure-ground, spatial relationships, visual closure, (which will be explored in more detail when we look at each Ax).

6. Theories of Perception Luria’s Functional Systems Model (1975) Model based on brain functioning Interaction of various regions in the brain is the cause of all human cognition and functioning Grouped areas into 3 distinct functional units Each unit does NOT work in isolation of each other Luria’s Functional Systems Model – developed in 1975 by a Russian neuropsychologist, Luria. This model is based on brain functioning Luria identified that cooperation & interaction of various anatomical regions in the brain, was the cause of all human cognition & f’x’g. Groupings were coined functional units. He identified 3 functional units which he noted did NOT work in isolation of each other (as no part of the brain functions completely independently) Luria’s Functional Systems Model – developed in 1975 by a Russian neuropsychologist, Luria. This model is based on brain functioning Luria identified that cooperation & interaction of various anatomical regions in the brain, was the cause of all human cognition & f’x’g. Groupings were coined functional units. He identified 3 functional units which he noted did NOT work in isolation of each other (as no part of the brain functions completely independently)

7. Theories of Perception (2) Luria cont’d First Functional Unit: Brainstem & reticular formation Arousal and activation Involved in regulating tone, waking, and mental states Stimulates us enough so we can do what we have/need to do Also responsible for basic need states (hunger, fight/flight responses) Brain injury often results in deficits in the 1st functional unit The 1st f’x’al unit is comprised of the brainstem & reticular formation & maintains f’x’g of arousal & activation. Thus it is involved in regulating our tone, waking, & mental states [allows us to be stimulated enough so we can do what we have/need to do] Also, this unit has been found to be responsible for basic need states (ie. hunger, fight/flight responses) Often having a brain injury can result in deficits in the 1st functional unit.The 1st f’x’al unit is comprised of the brainstem & reticular formation & maintains f’x’g of arousal & activation. Thus it is involved in regulating our tone, waking, & mental states [allows us to be stimulated enough so we can do what we have/need to do] Also, this unit has been found to be responsible for basic need states (ie. hunger, fight/flight responses) Often having a brain injury can result in deficits in the 1st functional unit.

8. Theories of Perception (3) Luria cont’d Second Functional Unit: **Where [visual] perception comes into play** Posterior cortex; including the occipital, parietal, and temporal lobes Occipital lobe is key for visual perception Sensation and perception Each lobe is made up of 3 areas: primary, secondary, tertiary **This unit is where visual perception comes into play** It is comprised of the posterior cortex; including the parietal, temporal, & occipital lobes…..the occipital is key for visual perception. f’x’g of the 2nd unit involves sensation & perception Each of the comprised lobes has a primary, secondary & tertiary area (each with increasing levels of integration):**This unit is where visual perception comes into play** It is comprised of the posterior cortex; including the parietal, temporal, & occipital lobes…..the occipital is key for visual perception. f’x’g of the 2nd unit involves sensation & perception Each of the comprised lobes has a primary, secondary & tertiary area (each with increasing levels of integration):

9. Theories of Perception (4) Luria cont’d Primary: Registers basic sensory information (ie. Auditory, visual, tactile) Secondary: Sensations are integrated into actual perceptions Ex. Sensations of light and structure becomes a perceived object Tertiary: Complex integration and elaboration of information Ex. Reaching in your pocket and picking out a penny as opposed to a dime Ex. Interpreting verbal and nonverbal aspects of communication – ie. Smile (happy) Primary Area: This area registers basic sensory information such as auditory, visual, & tactile. Secondary Area: At this level, sensations are integrated into actual perceptions. Thus, the sensation of light & structure becomes a perceived object such as a book. Tertiary Area: This area is involves extremely complex integration & elaboration of information – it is here where we often take our [visual] perceptual abilities for granted. Ex. Reaching in our pockets & picking out a penny as opposed to a dime. Ex. Interpreting verbal & nonverbal aspects of communication Ie. when we see someone smile we perceive the person as being happy as opposed to sad. Primary Area: This area registers basic sensory information such as auditory, visual, & tactile. Secondary Area: At this level, sensations are integrated into actual perceptions. Thus, the sensation of light & structure becomes a perceived object such as a book. Tertiary Area: This area is involves extremely complex integration & elaboration of information – it is here where we often take our [visual] perceptual abilities for granted. Ex. Reaching in our pockets & picking out a penny as opposed to a dime. Ex. Interpreting verbal & nonverbal aspects of communication Ie. when we see someone smile we perceive the person as being happy as opposed to sad.

10. Theories of Perception (5) Luria cont’d Third Functional Unit: Comprised of the frontal lobes Maintains executive functioning and control over thought processes & actions Main function is to inhibit unwanted information and behaviour. It is involved in programming, regulating and verifying behaviour This area is comprised of the frontal lobes It f’x’s to maintain executive functioning & control over thought processes & actions. This unit’s main function is to inhibit unwanted information & behaviour. Thus, it is involved in programming, regulating, & verifying behaviour. Deficits here are marked in disinhibited behaviour which is characteristic of many ABIs involving the frontal lobe.This area is comprised of the frontal lobes It f’x’s to maintain executive functioning & control over thought processes & actions. This unit’s main function is to inhibit unwanted information & behaviour. Thus, it is involved in programming, regulating, & verifying behaviour. Deficits here are marked in disinhibited behaviour which is characteristic of many ABIs involving the frontal lobe.

11. Theories of Perception (6) Piaget’s Theory of Cognitive Development Jean Piaget (Developmental psychology) “How we come to know” “Abstract symbolic reasoning” Assimilation & Accommodation Jean Piaget was a significant researcher in the realm of Dev’t Psychology whose preliminary interest was that of “how we come to know” He was a firm believer that the difference between animals and humans is our ability to use abstract symbolic reasoning Lastly, Piaget described 2 processes used by people to adapt, which are ASSIMILATION AND ACCOMMODATION Assimilation ? changing the environment to fit our existing cognitive structures Accommodation ? altering cognitive structures to fit the environmentJean Piaget was a significant researcher in the realm of Dev’t Psychology whose preliminary interest was that of “how we come to know” He was a firm believer that the difference between animals and humans is our ability to use abstract symbolic reasoning Lastly, Piaget described 2 processes used by people to adapt, which are ASSIMILATION AND ACCOMMODATION Assimilation ? changing the environment to fit our existing cognitive structures Accommodation ? altering cognitive structures to fit the environment

12. Motor-Free Visual Perceptual Test (MVPT) Authors: R. Colarusso & D. Hammill 1972 The 1st Ax we are going to look at is the Motor-Free Visual Perceptual Test – developed by Colarusso & Hammill in 1975.The 1st Ax we are going to look at is the Motor-Free Visual Perceptual Test – developed by Colarusso & Hammill in 1975.

13. MVPT (2) Purpose To measure visual perception free of motor involvement Used for screening, diagnostic, and for research purposes. SHANNON/Gianna??SHANNON/Gianna??

14. MVPT (3) Domains Figure Ground: Ability to distinguish an object from its background Spatial Relationships: Ability to switch the position of objects in relation to oneself and/or other objects Orienting one’s body in space & to perceive the positions of objects in relation to oneself & to others Discrimination: Ability to distinguish dominant feature in different objects SHANNONSHANNON

15. MVPT (4) Domains cont’d Visual Closure: Ability to identify an incomplete figure when only parts of it are present Visual Memory: Ability to recall dominant features of one stimulus item or remember sequence of several items Chosen because at time test was developed, they were the most prominent theoretical constructs in the literature SHANNONSHANNON

16. MVPT (5) Target Population Standardized on a sample of 4 children aged 8 years old. A revised edition was developed for use with the adult population (Bouska & Kwatny, 1983) MVPT-R was published in 1996 by the original authors Addresses issues of incomplete and outdated normative data (increasing ages of children to 9-11 years) Also, added 4 more items NO re-standardization from the 1972 data SHANNONSHANNON

17. MVPT (6) Administration Procedures Administered individually/ approximately 10 minutes Well-lit, distraction free environment Testing books in the client’s midline Examiner on left or right client, providing clear information If client has hemianopsia, examiner should sit on client’s intact side SHANNONSHANNON

18. MVPT (7) 40 multiple choice questions each with a stimulus and 4 possible answers Assessor points to each – “look at this” Assessor then points to 4 potential responses – “find it here” Client points to his/her response Scoring: Assessor circles client’s responses on scoring sheet Only correct answers are recorded Raw score is calculated (sum of correct answers) SHANNONSHANNON

19. MVPT (8) Motor-Free Assessment of Visual Perception Other tests purport to measure visual perception but have a motor component (i.e.: drawing) which acts as a confounder for measuring visual perception. Practically most perceptual abilities are integrated with motor systems’ abilities SHANNONSHANNON

20. MVPT (9) Not comprehensive – Body Scheme and Right/Left Discrimination are not assessed Recommended to not be used exclusively to assess visual perceptual abilities Recommended that it be used with measures of functional performance (i.e. FIM) SHANNONSHANNON

21. MVPT (10) Many researchers have attested that seeing an object alone is of little practical use if you can’t perceive its shape, location, movement, or colour SHANNONSHANNON

22. MVPT: Bottom-Up Processing MVPT assesses visual perception by testing clients on domains of function such as figure-ground discrimination, etc. The authors of the test argue that these are the most prominent theoretical domains of visual perception when the test was designed. SHANNONSHANNON

23. MVPT: Bottom-Up Processing (2) However, the scores from each domain are added together, resulting in a single global score which means that the ability for the client to perform in any one domain is lost. Brown, Rodger, and Davis (2003) argue that this may mean that the test therefore has little practical or clinical use. SHANNONSHANNON

24. MVPT: Bottom-Up Processing (3) The authors state that it is not comprehensive (it does not measure body scheme or right/left discrimination) The MVPT was designed as a general screening and can serve this purpose by looking at skills in several bottom-up processes SHANNONSHANNON

25. MVPT: Top-Down Processing MVPT does not really assess top-down processing of visual information The results can be used to predict possible function The Introduction to the test states that the test should be used in conjunction with functional assessment to determine the true state of their visual perceptual abilities. SHANNONSHANNON

26. MVPT: Top-Down Processing (2) Therefore, using other assessment tools to look at Top-down processing such as the Functional Independence Measure (FIM) is essential for predicting functioning in clients. SHANNONSHANNON

27. MVPT: Luria’s Model of Brain Functioning Recognizes the cooperation & integration of various systems in brain functioning MVPT assesses visual perception in a motor-free way Systems involving perception are interrelated with other systems such as the motor system. Assessing visual perception occurs at the 2nd functional unit in Luria’s model.

28. MVPT: Luria’s Model of Brain Functioning (2) RECALL: 3 increasing levels of integration in each lobe involved in this unit. Registration of visual stimuli occurs at the primary area The secondary area turns sensations into perceptions. MVPT measures visual perception fitting here in Luria’s model. The tertiary area involves complex integration of these percepts. MVPT does not assess its integration with other systems, therefore, such visual perceptual abilities as interpreting non-verbal communication (ie. smile=happiness),is not assessed.

29. MVPT: Luria’s Model of Brain Functioning (3) Scoring in the MVPT are dichotomous; ie. either right or wrong Makes it difficult to assess the complexities of perception Dichotomy limits MVPT from assessing some types of agnosia Agnosia - Impaired object recognition not related to visual loss Can generate an adequate internal representation of a stimulus, but cannot recognize it

30. MVPT: Luria’s Model of Brain Functioning (4) Associative Agnosia Failure to recognize meaning of what is perceived Ex. A client with an ABI recognizes circles from squares, but does he know that what he is looking at is a circle/shape? Ability to match objects is assessed in the MVPT (clients w/ Associative are able to do) Associative is not directly assessed since it does not assess whether clients actually understand the meaning behind what they are perceiving

31. MVPT: Luria’s Model of Brain Functioning (5) Apperceptive Agnosia Failure to even perceive visual stimuli Able to sense and register sensory stimuli from the environment but cannot connect sensations to actual percepts. Thus the ability to perceive is deficient.

32. MVPT: Luria’s Model of Brain Functioning (6) MVPT assesses visual apperceptive agnosia indirectly The domains the MVPT assesses determine whether or not clients can perceive stimuli from the environment However, MVPT’s dichotomous scoring does not allow clinicians to understand the reasons for their answers

33. MVPT: Luria’s Model of Brain Functioning (7) Not congruent with visual perception having many shades of grey with the levels of processing ranging in complexity of integration Researchers found that clients’ who perform well on tests assessing visual processing of inanimate objects (as does MVPT), perform poorly on tests that assess animate objects (such as the Benton Facial Recognition) (Duchaine et al., 2003) This questions the validity of the MVPT and the generalizability of the findings to all visual stimuli

34. Neuroanatomy of Visual Perception The MVPT tests clients on perceptual abilities that may result from damage to different brain regions Figure Ground Lesion: non-dominant occipital lobe Spatial Relationships Tertiary zone perceptual deficit: related to impaired depth perception (lesion: right hemisphere visual cortex)

35. Neuroanatomy of Visual Perception (2) Visual Discrimination Parietal and temporal lobe damage. A disorder in visual discrimination involves an inability to attend to slight variations in form. Therefore, by asking the client to match shapes tests their ability to tell the difference between different forms.

36. MVPT Findings: Driving Abilities Safe driving requires the driver to integrate complex visual processing skills Mazer et al. argue that visual perceptual skills such as figure-ground discrimination, visual discrimination, spatial relations (all tested by the MVPT) determine the ability to notice and react to objects in the visual field which is required when driving.

37. MVPT Findings: Driving Abilities (2) People who failed the on-road driving test performed more poorly on the MVPT than those who passed in people who had suffered a stroke (Mazer et al.) However, the scores were not highly predictive of a pass. MVPT does not look at colour agnosia, simultagnosia, metamorphosia.

38. MVPT: Driving Abilities Driving, in addition to perceptual skills, requires judgment, and behavioural and cognitive skills that the MVPT does not test. However, the MVPT seems to cover many of the visual perceptual skills required for driving.

39. MVPT: Driving Abilities (2) Visual Discrimination Need to see shapes to distinguish signs and cars from other moving objects, see stop lights, etc. Figure Ground To see lines on the road, objects on the road that may be hazards

40. MVPT: Driving Abilities (3) Visual Memory To find one’s way around, follow landmarks and directions Spatial Relationships Ability to avoid hazards, find way around, change lanes, etc

41. Professional Opinion Mandy Lowe Toronto Rehabilitation Institute Important to build rapport to determine which MVPT to utilize Level of difficulty varies for each Scoring – sum of all parts: Does not inform intervention Norms are based on overall score (all domains) Easy to transport; bring to bedside Consent – risks and benefits: Results can be upsetting Could also be less upsetting than finding out on a functional task

42. Loewenstein Occupational Therapy Cognitive Assessment Authors: Itzkovich, M., Averbuch, S., & Elazar, B. 1974

43. Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Purpose Evaluating patients who have experienced brain-injuries (ie. traumatic head injuries, CVA, tumours) Provides an initial profile of the cognitive abilities of an individual; used as a starting point for OT intervention as well as a screening test for further assessment Provides a valid profile of a client's abilities and a measurable assessment of specific deficits to help plan treatment. LOTCA was developed at Loewenstein Rehabilitation Hosp in Israel in 1974 PURPOSE this battery is used in evaluating individuals who have experienced some sort of injury to the brain (ie. traumatic head injuries, CVA, tumours) provides a preliminary profile of a client’s cognitive abilities and a measurable assessment of specific deficits to help plan tmtLOTCA was developed at Loewenstein Rehabilitation Hosp in Israel in 1974 PURPOSE this battery is used in evaluating individuals who have experienced some sort of injury to the brain (ie. traumatic head injuries, CVA, tumours) provides a preliminary profile of a client’s cognitive abilities and a measurable assessment of specific deficits to help plan tmt

44. LOTCA (2) Focus Four areas; 20 subtests Orientation Visual & Spatial Perception (6 subtests) Visuomotor Organization Thinking Operations Target Populations Paediatric (? 6 y/o) Adult consists of 20 subtests/domains divided into four areas: Orientation Talks about place and time Visual & Spatial Perception What we’ll concentrate on in this presentation Visuomotor Organization Copying, drawing, & building/assembling Thinking Operations Conceptualization, identifying discrete features of objects Concentrate on ? VISUAL & SPATIAL PERCEPTION (6 domains) LOTCA was developed for both a paediatric and adult population Is applicable to children 6 y/o and above and also to an adult population LOTCA-G ? revised for older adults; addresses physical & mental factors that can accompany aging by offering larger components, reduced pictorial detail, multiple choice questions, & shorter administration time.consists of 20 subtests/domains divided into four areas: Orientation Talks about place and time Visual & Spatial Perception What we’ll concentrate on in this presentation Visuomotor Organization Copying, drawing, & building/assembling Thinking Operations Conceptualization, identifying discrete features of objects Concentrate on ? VISUAL & SPATIAL PERCEPTION (6 domains) LOTCA was developed for both a paediatric and adult population Is applicable to children 6 y/o and above and also to an adult population LOTCA-G ? revised for older adults; addresses physical & mental factors that can accompany aging by offering larger components, reduced pictorial detail, multiple choice questions, & shorter administration time.

45. Evaluation Approachof LOTCA 30-45 min to administer (for entire test) “Perception” is the active process of: Searching for the corresponding info, Distinguishing essential features of an object, Comparing the features with each other, Creating appropriate hypotheses, Comparing these hypotheses with original data (Luria, 1973) According to its standardized manual, the entire LOTCA assessment takes 30-45 min to administer As mentioned, we’ll concentrate primarily on the Visual & Spatial Perception section In the LOTCA manual, it’s noted that Alexander Luria defines ‘perception’ as an active process where a person:’ Searches for corresponding info Distinguishes these essential features of a particular object Compares the features w/one another Formulates relevant hypotheses, and then Compares these hypotheses w/the initial informationAccording to its standardized manual, the entire LOTCA assessment takes 30-45 min to administer As mentioned, we’ll concentrate primarily on the Visual & Spatial Perception section In the LOTCA manual, it’s noted that Alexander Luria defines ‘perception’ as an active process where a person:’ Searches for corresponding info Distinguishes these essential features of a particular object Compares the features w/one another Formulates relevant hypotheses, and then Compares these hypotheses w/the initial information

46. Evaluation Approachof LOTCA (2) Administration of LOTCA Components: cards, pictures, scissors & paper, picture “puzzle” Important to eliminate influence on the client during the test Scoring: 1 (low) – 4 (high) [ordinal] based on client’s ability for (independent) success with each test subtests can be altered to assist client normative scores available Examiner and client are INTERACTIVE throughout the test HOW LOTCA CONDUCTED: Examiner holds up cards with various pictures Also uses a test booklet. Scissors & paper Picture “puzzle” Examiner remains as ‘neutral’ as possible; no guidance/hinting & eliminate any influence of the client Scoring is based on an ordinal scale system; 1 = LOW, 4 = HIGH; scoring based on the individual’s success at the task (ie. done independently, w/o going to the ‘help book’ or modifying the tests to make them easier/different); subtests are scored individually (there is NO overall tests core) Normative scores are in the manual both for children & adultsExaminer and client are INTERACTIVE throughout the test HOW LOTCA CONDUCTED: Examiner holds up cards with various pictures Also uses a test booklet. Scissors & paper Picture “puzzle” Examiner remains as ‘neutral’ as possible; no guidance/hinting & eliminate any influence of the client Scoring is based on an ordinal scale system; 1 = LOW, 4 = HIGH; scoring based on the individual’s success at the task (ie. done independently, w/o going to the ‘help book’ or modifying the tests to make them easier/different); subtests are scored individually (there is NO overall tests core) Normative scores are in the manual both for children & adults

47. Piaget’s Theory of Cognitive Development Jean Piaget (1896-1980) Developmental psychology Interest ? “how we come to know” Ability to do “abstract symbolic reasoning” Jean Piaget was a very influential researcher in the area of developmental psychology Aside: was a child prodigy; published first article at 11 y/o He had an initial interest of “how we come to know” Piaget believed a distinguishing characteristic between humans and other animals is our ability to utilize abstract symbolic reasoning Jean Piaget was a very influential researcher in the area of developmental psychology Aside: was a child prodigy; published first article at 11 y/o He had an initial interest of “how we come to know” Piaget believed a distinguishing characteristic between humans and other animals is our ability to utilize abstract symbolic reasoning

48. Piaget’s “Cognitive Development” (2) Began to work with children and investigate their thought processes Noted young children’s answers were qualitatively different than those of older children Younger children answered differently because they thought distinctively, not because they were less knowledgeable While working in Paris, Piaget became interested in how children think Noticed the answers of young children were qualitatively different than those of older children This suggested to him that the younger children were not less knowledgeable but, instead, answered the Q’s differently than their older peers b/c they thought differently This implies that human dev’t is qualitative rather than quantitativeWhile working in Paris, Piaget became interested in how children think Noticed the answers of young children were qualitatively different than those of older children This suggested to him that the younger children were not less knowledgeable but, instead, answered the Q’s differently than their older peers b/c they thought differently This implies that human dev’t is qualitative rather than quantitative

49. Piaget’s “Cognitive Development” (3) Two aspects to Piaget’s theory: 1. Process of coming to know, and 2. Stages we move through as we gradually acquire this ability Process of Cognitive Development: “Intelligence” = how an organism adapts to its environment Believed behaviour is controlled through schemes 2 aspects to Piaget’s theory: 1. Process of coming to know, and 2. Stages we move thru as we acquire this ability over time Piaget was interested in how we adapt to our environment (what he called “intelligence”) SCHEMES = representations that the individual uses to represent the world and to designate appropriate action accordingly 2 aspects to Piaget’s theory: 1. Process of coming to know, and 2. Stages we move thru as we acquire this ability over time Piaget was interested in how we adapt to our environment (what he called “intelligence”) SCHEMES = representations that the individual uses to represent the world and to designate appropriate action accordingly

50. Piaget’s “Cognitive Development” (4) “Equilibration” = drive to obtain balance between schemes and the environment Assimilation Transforming and placing the environment in pre-existing cognitive structures Accommodation Changing cognitive structures in order to accept something from the environment This adaptation is driven by a biological drive to obtain balance b/w schemes & the env’t Piaget described two processes used by an individual to adapt: ASSIMILATION & ACCOMMODATION; both are used throughout life as one adapts in a more complex manner ASSIMILATION = process of using/transforming the environment so that it can be placed in pre-existing cognitive structures EXAMPLE ? infant: when growing, bottle size also increases & they use the schema developed with the small bottle ? transfer to lg bottle ACCOMMODATION = process of changing cognitive structures so they can accept something from the env’t EXAMPLE ? modifies schema developed by sucking on a pacifier to a successful schema for using a bottle This adaptation is driven by a biological drive to obtain balance b/w schemes & the env’t Piaget described two processes used by an individual to adapt: ASSIMILATION & ACCOMMODATION; both are used throughout life as one adapts in a more complex manner ASSIMILATION = process of using/transforming the environment so that it can be placed in pre-existing cognitive structures EXAMPLE ? infant: when growing, bottle size also increases & they use the schema developed with the small bottle ? transfer to lg bottle ACCOMMODATION = process of changing cognitive structures so they can accept something from the env’t EXAMPLE ? modifies schema developed by sucking on a pacifier to a successful schema for using a bottle

51. Piaget’s “Cognitive Development” (5) Schemes (more complex) Structures (more complex) Hierarchy As schemes become increasingly more complex (ie. responsible for more complex behaviours) they are termed structures As structures increase in complexity, they are organized in a hierarchical manner (ie. from general to specific)As schemes become increasingly more complex (ie. responsible for more complex behaviours) they are termed structures As structures increase in complexity, they are organized in a hierarchical manner (ie. from general to specific)

52. Luria’s Theory of Functional Systems Brain = Organized system 3 “Blocks” 1. Brainstem 2. Area posterior to central sulcus 3. Area anterior to central sulcus Alexander Luria = Russian neuropsychologist Looks at how the brain is “mapped” & how these structures are involved in complex behaviours 3 “BLOCKS” (aka functional units) [DRAW A DIAGRAM OF A BRAIN] ?; each block responsible for a variety of basic functions (response to stimuli, coding/storage of information, formation of intentions, etc.) 1. Includes brainstem and the old cortex 2. Area posterior to central sulcus 3. Area anterior to central sulcusAlexander Luria = Russian neuropsychologist Looks at how the brain is “mapped” & how these structures are involved in complex behaviours 3 “BLOCKS” (aka functional units) [DRAW A DIAGRAM OF A BRAIN] ?; each block responsible for a variety of basic functions (response to stimuli, coding/storage of information, formation of intentions, etc.) 1. Includes brainstem and the old cortex 2. Area posterior to central sulcus 3. Area anterior to central sulcus

53. Luria’s “Functional Systems” (2) Functional Units (‘Blocks’) Interact with one another to produce optimal performance on a task 1st Functional Unit Role in attention and memory, in part by processing information according to its salience (relevance, importance and novelty) 1st Functional Unit ? has role in attention & memory; processes info according to its significance1st Functional Unit ? has role in attention & memory; processes info according to its significance

54. Luria’s “Functional Systems” (3) 2nd Functional Unit Primary role in perception Registers & integrates sensory information into perceptions 3rd Functional Unit Executive control Control over complex sequences of activity 2nd Functional Unit ? primary task of this second functional unit involves sensation and PERCEPTION Recognizes and incorporates sensory info into perceptions EXAMPLES (NB for LOTCA’s subtests) Recognizing a friend’s face or name an object Interpreting the verbal aspect of communication 3rd Functional Unit ? manage intricate movement sequences EXAMPLES (NB for LOTCA’s subtests) Eye movements during visual exploration Cognitive flexibility Accurate self-awareness For example, during this lecture: must have a certain level of wakefulness (first functional unit) plus the ability to see and make sense out of what you read (second functional unit) and maintain some level of control over your attention, intention, learning and behavior (third functional unit)2nd Functional Unit ? primary task of this second functional unit involves sensation and PERCEPTION Recognizes and incorporates sensory info into perceptions EXAMPLES (NB for LOTCA’s subtests) Recognizing a friend’s face or name an object Interpreting the verbal aspect of communication 3rd Functional Unit ? manage intricate movement sequences EXAMPLES (NB for LOTCA’s subtests) Eye movements during visual exploration Cognitive flexibility Accurate self-awareness For example, during this lecture: must have a certain level of wakefulness (first functional unit) plus the ability to see and make sense out of what you read (second functional unit) and maintain some level of control over your attention, intention, learning and behavior (third functional unit)

55. Influence of Piaget & Luria’s Theories on LOTCA Piaget Young vs old children; qualitative vs quantitative Use of schemes, assimilation & accommodation Schemes ? Structures ? Hierarchy Luria 2nd Functional Unit: primary role in perception 3rd Functional Unit: executive functions Interplay between Functional Units Piaget Some of the aspects of Piaget’s theory are more applicable to the other 3 sections of the LOTCA we didn’t touch on (ie. classification of objects into different categories and categorizing & sequencing tests) Believed young children were not less knowledgeable than their older peers ? they merely thought differently; there was a qualitative difference versus a quantitative one Use of schemes, assimilation, & accommodation to represent the world and modify their behaviour appropriately (SCHEMES), to change the env’t to fit with pre-existing cognitive structures (ASSIMILATION), and vice versa, to change one’s existing cognitive structures to fit with the environment (ACCOMMODATION) Luria 2nd F.U. ? its main role is to register & integrate sensory info into perceptions 3rd F.U. ? affects executive control & complex movements; which are areas on which LOTCA touches Interreaction b/w each of the 3 function units (no part of the brain operates with complete independence) The functional units all interact to product optimal performance on any taskPiaget Some of the aspects of Piaget’s theory are more applicable to the other 3 sections of the LOTCA we didn’t touch on (ie. classification of objects into different categories and categorizing & sequencing tests) Believed young children were not less knowledgeable than their older peers ? they merely thought differently; there was a qualitative difference versus a quantitative one Use of schemes, assimilation, & accommodation to represent the world and modify their behaviour appropriately (SCHEMES), to change the env’t to fit with pre-existing cognitive structures (ASSIMILATION), and vice versa, to change one’s existing cognitive structures to fit with the environment (ACCOMMODATION) Luria 2nd F.U. ? its main role is to register & integrate sensory info into perceptions 3rd F.U. ? affects executive control & complex movements; which are areas on which LOTCA touches Interreaction b/w each of the 3 function units (no part of the brain operates with complete independence) The functional units all interact to product optimal performance on any task

56. Domains of the LOTCA 6 Subtests ? Visual Identification of Objects ? Visual Identification of Shapes ? Overlapping Figures ? Object Constancy ? Spatial Perception ? Praxis Specifically, it looks at SIX domains (subtests) when assessing an individual’s perceptual abilities Specifically, it looks at SIX domains (subtests) when assessing an individual’s perceptual abilities

57. Two Types of Visual Testing Areas Visual Object Agnosia – inability to recognize objects presented visually, although primary visual skills are intact Visual Spatial Agnosia – defect in perceiving spatial relationships between objects, or objects and self Visual OBJECT Agnosia = first 2 subtests Visual SPATIAL Agnosia = last 4 subtests - NOTE ? it’s obviously crucial to assess vision beforehand by the appropriate individual (i.e. optometrist) using methods suitable to the client sine all subtests but the 2 in the “Orientation” section rely heavily/exclusively on unimpaired visionVisual OBJECT Agnosia = first 2 subtests Visual SPATIAL Agnosia = last 4 subtests - NOTE ? it’s obviously crucial to assess vision beforehand by the appropriate individual (i.e. optometrist) using methods suitable to the client sine all subtests but the 2 in the “Orientation” section rely heavily/exclusively on unimpaired vision

58. ? Visual Identification of Objects What It’s Measuring Associative Visual Agnosia (some Aperceptive Agnosia) Example: individual with associative agnosia, able to copy pictures but cannot recognize object

59. Example: Name these common animals

60. Neuroanatomical cause Lesions typically located in right hemisphere in posterior multimodal association area How to Administer Client shown 8 cards with common objects (chair, teapot, watch, key, shoe, bicycle, scissors, glasses) Name objects

61. ? Visual Identification of Objects (4) If Client is Having Difficulty Person has global or receptive/expressive aphasia Problems with Test Does not test for Prosopagnosia (inability to identify known individuals by face) Trial and error of matching board Unsure what test can be measuring

62. ? Visual Identification of Shapes What it is Measuring Visual Agnosia Example: Individual unable to copy and match simple forms (letters) and geometric shapes

63. ?Visual Identification of Shapes (2) Neuroanatomical Cause Lesions typically located in right hemisphere in posterior multimodal association area How to Administer Client shown 8 cards with solid geometric shapes (square, triangle, circle, rectangle, diamond, semi-circle, trapezoid, hexagon) Name objects

64. ?Visual Identification of Shapes (3) If Client is Having Difficulty Client cannot verbally name shape due to aphasia, expressive problems, or educational background Use matching board Problems with Test Test consists of four easy shapes and four more complex ones However, a score of ‘4’ can be attained if patient identifies shapes by naming and/or matching

65. ? Overlapping Figures What It’s Measuring Figure-Ground Neuroanatomical Cause Damage/lesion to non-dominant occipital lobe

66. ? Overlapping Figures (2) How to Administer Two cards with three overlapping figures on each card (a. banana, pear, apple; b. pliers, hoe, saw) Client is asked to name all figures seen on card If Client is Having Difficulty Board is shown with 6 figures (3 are figures on the card, 3 are different figures) Client has to point to what figures are seen on the card

67. ? Overlapping Figures (3) Problems with Test Does not: Incorporate real, ”everyday” images/pictures, and pictures with colour Include objects that have more similar features to one another Example: What objects do you see? “Everyday” images/pictures– cluttered work-desk, drawer Colour photos (in lieu of drawings)“Everyday” images/pictures– cluttered work-desk, drawer Colour photos (in lieu of drawings)

68. ? Object Constancy What It’s Measuring Form Constancy Dysfunction

69. ? Object Constancy (2) Neuroanatomical Cause Lesion in right parietal, temporal, and occipital lobe areas How to Administer Client shown photographs of objects taken from unusual angles (car, hammer, telephone, fork) Asked what is seen in photograph If Client is Having Difficulty If client has aphasia, he/she is asked to match the picture to the one that suits the big one on a board that has 4 pictures

70. ? Object Constancy (3) Problems with Test Does not test for letters and numbers Example: Point out letters O, Q, and D -only objects; no letters and numbers-only objects; no letters and numbers

71. ? Spatial Perception What It’s Measuring R-L Discrimination Somatogonosia Position in Space Dysfunction Neuroanatomical Cause Typically parietal lobe and/or posterior temporal lobe Left hemisphere What It’s Measuring - State definitions for all 3What It’s Measuring - State definitions for all 3

72. ? Spatial Perception (2) How to Administer a) OT asks client to perform simple movements (recognize directions on themselves) b) Orientation between objects (box & pencil) c) Recognizing directions on person in front of them - Explain - Explain

73. ? Spatial Perception (3) Problems with Test Client with language barrier or severe receptive aphasia may not understand instructions Clients with arthritis and/or poor fine motor abilities may have difficulties Items with larger surface-areas

74. ? Praxis What It’s Measuring Praxis = motor planning Measures the ability to execute motor functions Associative visual agnosia Anatomical Cause Motor apraxia = caused by lesion to the premotor cortex on the opposite side of the affected limb Frontal Lobe ? motor planning & executive functioning

75. ? Praxis (2) How to Administer a) Motor imitation – client imitates movements by experimenter (hand to ear/head/shoulder) b) Object utilization – experimenter presents pairs of objects and asks client how to use them (scissors & paper, envelope & paper) c) Symbolic actions – client is asked what they would do when they smell flower, open door with key

76. ? Praxis (3) Problems with Test If receptive aphasia exists client may have difficulty with understanding or following instructions Possibility exists that lesion to frontal lobe may be the (major) cause of having difficulty with the test; may not be a perceptual issue Motor dysfunction

77. What’s Missing? Test for Simultagnosia? Patient cannot interpret visual stimulus as a whole Could only point out individual letters or features Test for Colour Agnosia? Test for Metamorphosia? Object may be recognized accurately, but appears larger or smaller than it actually is Potential problems with ADL functioning

78. Potential Difficulties Cultural barriers (i.e. person may not be familiar with the object being shown) Language barriers (ESL-individual may know what object is, but cannot express in English) Some subtests would not be feasible to adapt for persons with receptive/ expressive aphasia, and individuals with fine/gross motor difficulties Language Barriers – translator would most likely be present, however, it can be difficult to locate translator, could extend test duration, etc.Language Barriers – translator would most likely be present, however, it can be difficult to locate translator, could extend test duration, etc.

79. Potential Difficulties (2) Questionable if test can really assess how person would perform in actual situations (top-down component should be added) Underlying problems, such as unilateral spatial neglect, may skew results if unknown by examiner (Katz, 1999) Stewart & Schindler found that individuals without brain injury did not attain a perfect score on the LOTCA LOTCA merely looks at occupational components of situations (i.e. visuospatial perceptual); does not address how the person behaves in certain situations Since “normal” people failing to attain a perfect score ? is the LOTCA ‘realistic’ for individuals with brain injuries?LOTCA merely looks at occupational components of situations (i.e. visuospatial perceptual); does not address how the person behaves in certain situations Since “normal” people failing to attain a perfect score ? is the LOTCA ‘realistic’ for individuals with brain injuries?

80. LOTCA Findings: Dressing Oneself Successful and efficient dressing requires utilizing integration of perceptual skills One’s abilities in visual perceptual skills are related to particular aspects of identifying and selecting specific articles of clothing

81. LOTCA Findings: Dressing Oneself (2) Visual Identification of Objects & Visual Identification of Shapes Inability to find clothes (identifying shape of pants, belt, ties, long-sleeved vs short-sleeved) Recognition of clothing – if individual cannot recognize the article of clothing, he/she may not know its purpose and how to wear it (where do socks go on one’s body?)

82. LOTCA Findings: Dressing Oneself (3) Overlapping Figures Difficulty locating clothes in closet, dresser (socks/underwear in drawer) Experience increased difficulties if clothes are similar in colour to other articles of clothing and/or where they are stored (closet, drawer)

83. LOTCA Findings: Dressing Oneself (4) Object Constancy Difficulty recognizing clothes/items in various arrangements (ie. shirt folded vs on hanger) Orientate clothing incorrectly (put on inside out, backwards) Select “wrong” items ? wear spouse’s clothes

84. LOTCA Findings: Dressing Oneself (5) Spatial Perception Put shoes on wrong feet; difficulties putting sweater on (ie. video with gentleman) Unawareness of own body parts may exist and client may have difficulty with concepts related to body positions and deciphering between ‘left’ and ‘right’

85. LOTCA Findings: Dressing Oneself (6) Praxis May have difficulty putting a t-shirt on (bringing hands to head) Confusion with respect to knowing how to put a belt through the pant loops

86. Professional Opinion Mandy Lowe Toronto Rehabilitation Institute Important to tread carefully and use the appropriate test at the appropriate level of functioning (frustration, self-esteem issues) Identifies difficulties in real life (ecological validity) Correlated with FIM & Mini-Mental No overall score; need motor control/abilities Doesn’t touch much on processing speed Need table/area to move items around

87. Professional Opinion (2) Nicky Brookes Hospital for Sick Children Paediatrics; prefers LOTCA for 10-16 y/o However, she feels the variation in scores at the ends of the age-range makes it less reliable/valid and prefers LOTCA for 13 & 14 y/o ‘Visual & Spatial Perception’ section in LOTCA is similar to other tests Believes it is a valid and reliable assessment tool; easy to administer; enjoys using it Nicky Brookes (Sick Kids, TA for OCT1122 – Res. Methods) Works in paediatrics, prefers the LOTCA for 10-16 y/o children She feels the variability at the extremes of the age-range is too great Prefers to use it for 13 & 14 y/o’s Specifically, with the ‘Visual & Spatial Perception’ section: It is similar to other tests out there If she wished to only test visual & spatial perception she may go with an alternative test She thinks that as an assessment tool, the LOTCA is reliable & valid, and she also finds it easy to administer and enjoys using itNicky Brookes (Sick Kids, TA for OCT1122 – Res. Methods) Works in paediatrics, prefers the LOTCA for 10-16 y/o children She feels the variability at the extremes of the age-range is too great Prefers to use it for 13 & 14 y/o’s Specifically, with the ‘Visual & Spatial Perception’ section: It is similar to other tests out there If she wished to only test visual & spatial perception she may go with an alternative test She thinks that as an assessment tool, the LOTCA is reliable & valid, and she also finds it easy to administer and enjoys using it

89. Internal Consistency ? is it too high?Internal Consistency ? is it too high?

92. Thank You

93. References Brown, G.T., Rodger, S., & Davis, A. (2003). Motor-free Visual Perception Test-Revised: An overview and critique. British Journal of Occupational Therapy, 66(4), 159-167. Burtner, P.A., Ortega, S.G., Morris, C.G., Scott, K., & Qualls, C. (2002). Discrimination validity of the Motor-Free Visual Perceptual Test Revised in children with and without learning disabilities. Occupational Therapy Journal of Research, 22, 161-163. Burtner, P.A., Qualls, C., Ortega, S.G., Morris, C.G., & Scott, K. (2002). Test-retest reliability of the Motor-Free Visual Perception Test Revised (MVPT-R) in children with and without learning disabilities. Physical and Occupational Therapy, 22, 23-36. Kamble, R., Goswami, S., Saigal, J., Sarin, R., & Jalali, R. (2003). Prospective neuro-cognitive assessment (using LOTCA) and quality of life (QOL) and activities of daily living (ADL) in children with brain tumour treated with surgery and localized high-precision radiotherapy. The Indian Journal of Occupational Therapy, 25, 10-12.

94. References (2) Itzkovich, M., Elazar, B., & Averbuch, S. (1993). LOTCA: Loewenstein occupational therapy cognitive assessment. Pequannock, NJ: Maddak Inc. Katz, N., Itzkovich, M., Averbuch, S., & Elazar, B. (1989). Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery for brain-injured patients: Reliability and validity. The American Journal of Occupational Therapy, 43, 184-192. Leonard, P., Foxcroft, C., & Kroukamp, T. (1988). Are visual-perceptual and visual-motor skills separate abilities? Perceptual and Motor Skills, 67, 423-426. Mazer, B.L., Korner-Bitensky, N.A., & Sofer, S. (1998). Predicting ability to drive after stroke. Archives of Physical and Medical Rehabilitation, 79, 743-749. Su, C.Y.; Chang, J.J., Chen, H.M., Su, C.J., Chien, T.H., & Huang, M.H. (2000). Perceptual differences between stroke patients with cerebral infarction and intercerebral hemorrhage. Archives of Physical and Medical Rehabilitation, 81, 706-714.