Abstract
This study found moderate to high internal consistency for all EASI Praxis tests as well as significant correlations between age and praxis scores, indicating that the tests are sensitive to developmental changes.
Ayres Sensory Integration® (ASI) is an evidence- based practice that is widely used in occupational therapy (Schoen et al., 2019; Smith Roley et al., 2018; Steinbrenner et al., 2020). Comprehensive assessment before intervention is a cornerstone of this approach and is part of best practice (Schaaf & Mailloux, 2015). According to the American Occupational Therapy Association’s (AOTA’s) Choosing Wisely® initiative, “Interventions that do not target the documented patterns of dysfunction can produce ineffective or negative results. Therefore, it is imperative to assess and document specific sensory difficulties before providing sensory-based interventions, such as Ayres Sensory Integration” (AOTA, 2019, p. 1).
A. Jean Ayres (1966, 1972, 1989) developed sensory integration tests and applied them in her research on sensory integration (Parham & Mailloux, 2020). Her growing interest in the importance of assessing praxis as a central aspect of sensory integration is evident in her final set of assessments, the Sensory Integration and Praxis Tests (SIPT; Ayres, 1989). These tests include several assessments aimed specifically at assessing praxis functions. Ayres (1985) defined praxis as the ability to conceptualize novel actions (i.e., ideation), form plans to perform novel actions (motor planning), and ultimately execute actions successfully (motor performance).
Ayres (1985, 2011) acknowledged that praxis involves cognitive aspects (e.g., ideation, self-knowledge, and knowledge of objects), sensory aspects (e.g., tactile and proprioceptive perception), and motor abilities (Lane et al., 2014). Her research over several decades revealed patterns of function and dysfunction that link sensory perception to praxis (Ayres, 1965, 1989); specifically, she found that somatosensory perception is associated with body-centered praxis, that is, the ability to organize the body to assume novel positions or perform novel movement patterns (Ayres, 1985, 2011). She called this ability somatopraxis, with the term somatodyspraxia indicating dysfunction in this domain (Ayres, 1989).
The SIPT include several tests of praxis that have been highly associated with the somatopraxis pattern: postural praxis, oral praxis, sequencing praxis, and praxis on verbal command (Ayres, 1989; Mulligan, 1998; van Jaarsveld et al., 2014). The normative data for these tests revealed that children’s performance demonstrates clear age trends. Specifically, significant age differences are seen in the normative range of 4 yr, 0 mo to 8 yr, 11 mo, with a tendency for scores to start leveling out at the end of the age range (Ayres, 1989).
The Evaluation in Ayres Sensory Integration (EASI), a set of 20 tests aimed at assessing the core constructs of ASI, is designed for children and young adolescents ages 3 to 12 yr. (The World Health Organization [n.d.] and UNICEF [2019] have defined adolescence as a phase of life that begins at age 10 yr.) The EASI tests are under development, and international normative data collection is underway (Gándara-Gafo et al., 2021; Holmlund & Orban, 2020; Mailloux et al., 2018, 2021). The EASI includes four tests that measure distinct aspects of praxis: Praxis: Ideation (Pr: I; the ability to generate novel ideas for action), Praxis: Positions (Pr: P; the ability to accurately imitate static, unfamiliar body positions), Praxis: Sequences (Pr: S; the ability to accurately imitate a novel series of actions), and Praxis: Following Directions (Pr: FD; the ability to follow spoken verbal directions for performing a novel series of actions). The purpose of this study was to address the following research questions with a sample of typically developing Israeli children ages 6 to 12 yr: Are each of the four EASI Praxis tests valid measures of age-related developmental changes in praxis ability? Do the four EASI Praxis tests show acceptable internal consistency?
Method
This study was reviewed and approved by the Ethics Committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa (Approval No. 159/20). A cross-sectional developmental design was used to examine the performance of typically developing children ranging in age from middle childhood through early adolescence on four EASI Praxis tests.
Participants
We administered the four EASI Praxis tests to a convenience sample of 234 typically developing children and young adolescents (95 boys [40.6%], 139 girls [59.4%]) ranging in age from 6 yr, 0 mo to 12 yr, 11 mo (M = 8 yr, 8 mo, SD = 1 yr, 11 mo). All participants attended kindergarten to seventh-grade classes at various mainstream elementary schools in Israel. We verified typical development by asking parents to report whether their child had ever received a developmental diagnosis. We excluded children and young adolescents with known developmental or behavioral difficulties, such as previously identified problems with sensory integration, diagnosis of attention deficit hyperactivity disorder or developmental coordination disorder, previously identified learning disability, or similar conditions.
Most participants lived in urban settlements (n = 182; 77.8%); the rest lived in rural settings (n = 52; 22.2%). According to parents’ reports, 131 (56.0%) participants came from families of average socioeconomic status; 88 (37.6%), from families of high socioeconomic status; and 10 (4.3%) from families of low socioeconomic status. Data were missing for 5 (2.1%) participants.
Instruments
Data were gathered on participants’ demographic characteristics and their performance on the four EASI Praxis tests. We administered the following instruments to the children and young adolescents in the study or to their parents.
Demographic Information Questionnaire
The participants’ parents completed a demographic questionnaire that provided information about the child, such as age and gender, and about the family, such as socioeconomic status (high, average, or low relative to the average wage in the economy), parent education (high school or less, professional training, or academic graduation), and type of residence (rural or urban).
EASI Praxis Tests
Praxis: Ideation
The Pr: I test consists of four items that assess the child’s ability to create and demonstrate ideas about possible actions with (1) a chair, (2) hands, (3) everyday objects, and (4) the body. The examiner asks the child to show “everything they can do” in 60 s for each of the four items. The Pr: I is scored for tally and quality. For the tally score, the examiner records a tally mark for every distinct action the child makes in 60 s for each of the four items. Each item also receives three quality scores (speed, variety, and complexity) that range from 3 to 12; thus, the total quality score can range from 12 to 48. Higher tally and quality scores on each Praxis test indicate better performance.
Praxis: Positions
The 24-item Pr: P test measures the child’s ability to accurately imitate static body, hand, and face positions demonstrated by the examiner. Each Pr: P item is scored 2, 1, or 0 for accuracy, and the total score ranges from 0 to 48.
Praxis: Sequences
The Pr: S test has 27 items that assess the child’s ability to accurately imitate a series of actions with the body, hands, or face that are demonstrated by the examiner. Each Pr: S item is scored 2, 1, or 0 for accuracy; the total score ranges from 0 to 54.
Praxis: Following Directions
The 18-item Pr: FD test assesses the child’s ability to accurately perform a series of actions with the body, hands, and face in response to verbal directions from the examiner. The first two simple items are scored 0 or 1; the remaining 16 items are scored 0, 1, or 2 on the basis of specific criteria outlined in the test manual. The total score for this test ranges from 0 to 34.
The EASI was developed as a large international project with the purpose of translating and adapting it for use in measuring sensory integration functions worldwide. Therefore, it was designed in a manner that minimizes the influences of culture and language comprehension. However, a formal systematic, multistep process of translation of the Pr: FD from English to Hebrew was performed for our study, including translation synthesis in a focus group and back translation (Sousa & Rojjanasrirat, 2011), as has been done in other countries (e.g., Holmlund & Orban, 2020) to enable international normative data collection. At this time, studies reporting on the overall validity and reliability of the full set of EASI tests have been published (Gándara-Gafo et al., 2021: Holmlund & Orban, 2020; Mailloux et al., 2021; Schaaf et al., in press), or in preparation for submission.
Procedures
After the EASI was translated to Hebrew, occupational therapy students were trained to administer the Praxis tests in a manner similar to that of the normative data collectors for the EASI. Specifically, they (1) observed videotaped demonstrations, (2) practiced administration by means of simulations in small groups, and (3) established interrater reliability for the testers within each small group and with the researchers. Once interrater reliability of at least 80% for each of the four tests was established, each group of three students, one of whom administered the test and two who observed, was ready to collect data.
We recruited a convenience sample by contacting parents of children and young adolescents from the community in the specified age range and explaining the study. Parents who signed informed consent forms were invited to participate, and they completed the demographic questionnaires. The testing occurred in the participants’ homes, usually in a quiet room free of distractions but large enough for the required activities, and participants’ performance on all four tests was video recorded. The testers scored the tests during the assessment process but could also use the videotaped segments for further coding if needed.
Data Analysis
We conducted data analyses using IBM SPSS Statistics (Version 25.0). Descriptive statistics included frequencies, means, and standard deviations for demographics and for the scores on the four EASI Praxis tests. We used Cronbach’s α to examine internal consistency of each test, with the common interpretation of the coefficient as α < .5 for low reliability, .5 < α < .8 for moderate (acceptable) reliability, and α > .8 for high (good) reliability (Ekolu & Quainoo, 2019). We also calculated Pearson correlation coefficients to examine relationships between test scores and participants’ age, with a coefficient of >.70 indicating a strong relationship, a coefficient of .40 to .69 indicating a moderate relationship, and a coefficient of .30 to .50 indicating a weak relationship (Schober et al., 2018). We examined differences between test scores among age groups using one-way analysis of variance (ANOVA) with post hoc Scheffé correction (Ruxton & Beauchamp, 2008).
Results
Internal Consistency
Ranges, means, standard deviations, and internal consistency for each of the tests are presented in Table 1. Cronbach’s α indicated that each of the four tests had moderate to high internal consistency reliability (α = .55–.88).
EASI Praxis Tests: Score Means, Standard Deviations, and Ranges and Internal Consistency
Note. N = 234. EASI = Evaluation in Ayres Sensory Integration®.
Age Trends
We examined correlations between age (in months) and test scores using Pearson correlation coefficients. We found significant positive correlations of moderate magnitude between age and Pr: P (r = .42, p < .001), Pr: S (r = .46, p < .001), and Pr: FD (r = .36, p < .001). These moderate correlations indicated that as the children’s ages increased, scores tended to be higher, particularly for the Pr: P, Pr: S, and Pr: FD tests. We also found significant positive correlations between age (in months) and the Pr: I tally (r = .26, p < .001) and Pr: I quality (r = .24, p < .001) scores, although the correlations were low in magnitude, suggesting a somewhat weak, but detectable, relationship with age. Although consecutive age groups did not consistently demonstrate improvement with age on the Pr: I measures, the ANOVA tests with post hoc Scheffé correction to examine differences between age groups revealed significant differences overall across age groups for each test evaluated in this study (means, standard deviations, and ranges are presented in Table 2).
EASI Praxis Test Scores by Age and ANOVA Results
Note. N = 234. ANOVA = analysis of variance; EASI = Evaluation in Ayres Sensory Integration®; ns = nonsignificant.
p < .05.
p < .01.
p < .001.
Discussion
The EASI is an internationally normed set of tests designed to provide a practical and feasible tool for assessing sensory integration functions. The tests are designed for a broader age range (3–12 yr) than the SIPT (4–8 yr), which is the current gold standard for assessment of sensory integration. The primary aims of this study were to examine the internal consistency of the EASI Praxis tests (Mailloux et al., 2018) and to evaluate the validity of these tests as measures of developmental change in praxis from childhood through early adolescence.
Our findings indicated moderate to high internal consistency for the EASI Praxis tests in children and young adolescents ages 6 to 12 yr. However, the PR: FD test has a Cronbach’s α of .55, which is considered low to moderate internal consistency. This may indicate the heterogeneity of the items of this specific test, which may measure more than one concept (Ekolu & Quainoo, 2019). It may also suggest a problem in the translation or a cultural issue. Reassessing the content validity of the PR: FD items is recommended, as is examining whether such results are consistent across all cultures and languages.
An interesting finding is that although most of the Praxis tests strongly relate to each other, PR: I has low correlations with the other tests. This suggests that ideation differs in nature from the other aspects of praxis. Indeed, whereas most praxis components are visible, Ayres (1985) identified ideational praxis as a cognitive aspect of praxis. Despite the difficulty in assessing the cognitive aspect of ideation emergence, the high internal consistency reliability of this test and the very high correlation between the number of ideas and their quality indicate the ability of the EASI Praxis tests to also assess these aspects.
The results of the current study also indicate that praxis performance improves with age, representing a developmental trend from childhood into early adolescence. Past research suggested that sensory systems, as well as the motor functions that are dependent on them, mature around ages 6 to 8 yr (e.g., Ayres, 1985; Chang & Yu, 2018; Kools & Tweedie, 1975; Njiokiktjien et al., 2000). However, in this study we found that developmental changes in praxis continue at least into early adolescence (i.e., ages 11–12 yr).
Ayres (1985) theorized that praxis requires sensory perception and integration of cognitive and motor components. More recent research has supported this theory by associating motor skills with metacognitive abilities (Pratt et al., 2014; Toussaint-Thorin et al., 2013; Wilson et al., 2013). Moreover, multidisciplinary research suggests that both motor skills and neurocognitive domains emerge during early childhood and then strengthen significantly during late childhood and adolescence (e.g., Anderson et al., 2001; Best & Miller, 2010; Best et al., 2009; Roalf et al., 2014). The results of this study align with this research in that they support the likelihood that the motor and neurocognitive components on which praxis is based may continue to develop into early adolescence.
Our findings support the clinical usefulness of the extended EASI age range into early adolescence, that is, through age 12 yr. These findings highlight the importance of further investigation of praxis development, specifically whether age-related changes in the EASI Praxis tests are evident from early through late adolescence and the age at which the praxis developmental curve typically flattens, indicating maturity.
Limitations
Although the internal consistency of the EASI Praxis tests in this study was strong, our convenience sample was relatively small and homogeneous, both ethnically and culturally. Additional normative data using larger and more heterogeneous samples from diverse cultures and age groups spanning adolescence and adulthood are needed to deepen the understanding of praxis development in childhood and beyond. In addition, the psychometric results indicate that the PR: FD has moderate internal consistency; further research is needed to reconsider inclusion of those items. Finally, although the tool is intended for children ages 3 yr and older, the participants in the current study were ages 6 yr and older. To fully understand the praxis age trend, further studies should include the entire age range for which the tool is intended.
Implications for Occupational Therapy Practice
The results of this study have clinical implications for both assessment and intervention; specifically, they suggest that assessment of praxis may provide valuable clinical information for age groups spanning early childhood through early adolescence. The findings also indirectly raise the question of whether intervention aimed at improving praxis ability may be appropriate for older children and young adolescents whose praxis development is lagging compared with peers. This study has the following implications for occupational therapy practice: Occupational therapy practitioners can use the EASI Praxis tests with confidence that scores are valid and sensitive to developmental changes in praxis. Practitioners should assess praxis of young adolescents, as well as younger children, using the EASI Praxis tests. When assessment data indicate that a child’s or young adolescent’s praxis performance falls below typical expectations, intervention should be considered to support praxis development, with outcomes related to the young person’s needs and wishes in relation to occupational engagement.
Conclusion
This study suggests that the EASI Praxis tests (Pr: P, PR: S; Pr: I, and PR: FD) have strong internal consistency and validity in measuring the development of praxis in children and young adolescents ages 6 to 12 yr. A new finding presented in this study is that praxis development appears to continue through middle childhood into early adolescence. Although the occupational therapy literature on praxis has focused mainly on early and middle childhood, our findings suggest that praxis development should be studied further in adolescent and young adult populations (ages 11 or 12 through 24 yr).
Footnotes
Acknowledgments
We thank the students in a research seminar in the Department of Occupational Therapy, University of Haifa, for their part in this research.