Excessive Postrotary

Nystaglllus Duration in LearningDisabled Children

Kenneth Ottenbacher

The Southern California Sensory

Integration Test results of 109
learning-disabled children were
reviewed and analyzed to investigate the hypothesis that learningdisabled children with excessive
postrotary nystagmus durations
display greater neuropsychological
impairment than learningdisabled children with normal or
depressed postrotary nystagmus.
The findings supported the
hypothesis that learning-disabled
children judged to have relatively
greater neuropsychological involvement exhibited significantly
longer postrotary nystagmus durations. Data analysis revealed that
six Southern California Sensory
Integration Tests assumed to measure cortical level functions shared
significant variance with excessive
Southern Calzfornia Postrotary
Nystagmus Test (SCPNT) scores.
A similar relationship was not
found for normal or depressed
SCPNT scores. A connection
40

between cortical level versus brainstem level central nervous system

dYsfunction, nystagmus, and
learning disorder is discussed.

ecent neuropsychological research revealed dysfunction of

the vestibular system in significant
numbers of children identified as
learning disabled (1-3). The vestibular system, together with other
proprioceptors and the cerebellum,
serves to regulate posture, muscle
tone, body equilibrium, spatial orienta tion, and eye-head coordination
(4). Parents, educators, and therapists have noted for years that some
children identified as learning disabled exhibit varying degrees of

Kenneth Ottenbacher, M.S., OTR,

is Assistant Professor, Department
of Occupational Therapy, Health
Sciences Center, University of
Central Arkansas, Conway,
Arkansas.

January 1980, Volume 34, No.1

Downloaded From: http://ajot.aota.org/ on 05/14/2016 Terms of Use: http://AOTA.org/terms

impairment in areas related to vestibular functions, including deficiencies in postural reactions, coordination and body awareness. Ayres
recognized (in the 1960s) that some
learning-disabled children evidenced
vestibular and proprioceptive disorders incl uding a syndrome referred
to as disorders in "postural and
bilateral integration" (5, 6). This
syndrome, more recently termed vestibular bilateral integration, is partially characterized by poor equiIi bri urn reactions, poor oculomotor
control (the presence of) remnants
of primitive postural reflexes, hypotonic muscle tone, and abnormal
responses to vestibular stimulation.
All of these symptoms may be directly related to function or dysfunction
of the vestibular and proprioceptive
systems. de Quiros has also identi- .
fied vestibular-related disorders in
learning-disabled children (3, 7).
One syndrome referred to as vestibular proprioceptive disintegratzon
is characterized by muscle hypoto-

nia, poorly integrated postural mechanisms, delays in motor and language development, and deficient
vestibulo-ocular reflex to neurolabyrinthine (caloric) testing. de
Quiros and Schrager (2) recently
iden tified another rela ted syndrome
termed vestibular-oculomotor split,
which is characterized by impaired
ocular fixation and scanning abilities, and poor eye-head coordination.
Both Ayres (1,5,8) and deQuiros
(2,3,7) have repeatedly found significant numbers of children identified as learning disabled who display depressed or abnormal vestibular-ocular reflexes referred to as
nystagmus, following rotatory or
caloric vestibular stimulation. Independent researchers have conducted studies that tend to confirm
the existence of vestibular dysfunction within the learning-disabled
population. These investigations
have shown that children with vesti bular processi ng disorders display
characteristic soft or non/ocal neurological signs (9,10), a higher portion of certain language deficits
(II), and lower scores on tests of
visual-motor integration and reading achievement (12-14). Recently,
it has been shown that learningdisabled children may exhibit differential changes in postrotary nystagmus duration as a function of
sensory integrative therapy (15).
Introduction of the Southern California Postrotary Nystagmus Test
(SCPNT) by Ayres has provided a
quick, quantifiable measure of vestibular-ocular reflex following rotation in children 5-9 years of age (16).
The vestibular-ocular reflex following rotation is commonly referred
to as postrotary nystagmus (PRN).
Ayres' most recen t research revealed
that 50 percent of the learningdisabled children under study has

depressed PRN when tested with

the SCPNT (1,8). Thirty-seven percent had PRN within normal limits
and 13 percent had PRN that was
considered excessi ve. SCPNT scores
of less than -1.0 SD or grea ter than
+ 1.0 SD from the standardized mean
are interpreted as abnormal, although probably measuring different aspects of neurovestibular function (16). In the research referred to
above (Ayres), learning-disabled children with excessive SCPNT scores
(> + 1.0 SD) scored consistently lower
on neuropsychological and achievement tests than learning-disabled
children with normal or depressed
PRN. Ayres stated that "Children
with prolonged duration nystagmus, while fewer in number in this
population, appear to have greater
and more extensive neurological
involvement as measured by this
study" (I, p 25).
Occupational therapists treat children with sensory integrative disorders that may include dysfunction in the processing of vestibular
information. The therapist who is
aware of the nuances of vestibular
dysfunction is in a better position to
assist in differential diagnosis and
treatment of children with learning
disorders. The purpose of this study
was to broaden the diagnostic and
clinical significance of vestibular
dysfunction in learning-disabled
children by investigating the relationship of nystagmus duration to
the degree of neuropsychological
dysfunction in a sample of learning-disa bled chi ldren.

Procedures
This was a causal comparative study
in the sense that information concerning the variables under investigation was gathered ex post facto.
Subjects consisted of 71 male and 38
female children ranging in age from

58 to 116 months. All subjects had

medical and educational diagnoses
of learning disability and were referred to a children's rehabilitation
center for diagnostic testing and
treatment. Subjects' IQs were within
a normal range (80-120) as far as
could be determined from psychological and school reports. The 109
children were administered a battery of informal and formal assessment procedures including the Southern California Sensory Integration
Tests (SCSIT) and the SCPNT (16,
17). The tests were administered by
two therapists experienced in pediatric assessment, one of whom was
certified in the administration of
the SCSIT. The SCPNT was administered in a well-lighted room in
accordance with the standardized
instructions. The condi lions of admi nistration were the same for all subjects. A SCPNT score of> + 1.0 SD
was considered indicative of excessive PRN.
The presence of neuropsychological dysfunction in a population of
learning-disabled children is controversial and must be regarded as a
relative question. The criterion employed to operationally define greater or more ex tensi ve neuropsychological involvement for purposes of
this study was a combined SCSIT
mean score < -1.0 SD. Any subject
meeting this criterion on the SCSIT
was placed in Group I, designated
as having relatively greater or more
extensive neuropsychological involvement. All other subjects were
placed in Group II, designated as
having relatively less neuropsychological involvement. All of the SCSIT
subtests, except "DoubleTactileStimulation," not routinely given to all
su bjects and therefore not inel uded
in the analysis, were used to determine the overall SCSIT mean score
for each subject.

The American Journal

Downloaded From: http://ajot.aota.org/ on 05/14/2016 Terms of Use: http://AOTA.org/terms

0/ OccupatIOnal Therapy

41

Table 1
Characteristics Based on Degree
of Neuropsychological Involvement
Variable

Group I Group II

Sex
Male
Female
Total

26
8
34

54
21
75

86.27
1821
.59-108

91.61
12.42
58-116

2306
17.12
5-44

1178
10.70
0-33

Age (Months)
Mean

SD
Range

PRN Duration
Mean

SD
Range

Results
Forty-nine (45%) of the 109 subjects
evidenced SCPNTscores of less than
-1.0 SD. Forty-five (41%) of the subject had SCPNT scores between -1.0
SD and + 1.0 SD, and IS (14%) of the
subjects and SCPNTscores of greater than +1.0 SD. Thirty-four (31%)
of the 109 subjects had a combined
mean score of < -1.0 SD on the
SCSIT These 34 made up Group 1.
Descriptive data for the two subject
groups appear in Table I.
A chi-square for independence
was computed between SCPNT test
scores and degree of neuropsychological involvementas measured by
the SCSIT with a resultant XZ =
16.88. The null hypothesis that degree of neuropsychological involvement and PRN duration were
independent was rejected at the p <
.01 level. An unequal N 2 x 3 analyses of variance (ANOVA) confirmed the conclusion suggested by
the chi-square analysis. The differential responsiveness of the SCSIT
groups based on PRN durations
was indicated by a significant main
effect (Fe'I)J = 5.25 P
42

A multiple regression equation

was generated to determine which
of the neuropsychological variables
as measured by the SCSIT differentia ted those ch iIdren wi th h yperresponsive PRN. Multiple regression analysis allows the researcher
to predict the outcome of one dependent or criterion variable from
several independent or predictor variabIes considered simultaneously.
The SCSIT scores for the 15 children with hyper-responsive PRN
served as the independen t or predictor variables, and SCPNT scores>
+ I SD served as the dependent or
criterion variable. Variable coding
was performed according to Cohen
and Cohen (18), using a program of
subsets developed by Schatzoff and
otbers (19). The genera tion of a
regression equation yields an RZ
value that equals the proportion of
the variance of the dependent variable (excessive PRN) accounted for
by the independent variables (SCSIT
scores). The RZ for the equation was
.5912 and the standard error of estimate was .21. Thus, the regression
model accounted for approximately
59 percent of the variance in the
dependent variable (excessive PRN)
in terms of the SCSIT scores. The
computation of regression equations and accompanying R Z values
when the sample size is not at least
three times larger than the number
of independent variables (k) is regarded by some a uthori ties as can troversial (20) and may result in an inflated
RZ value. Cohen and Cohen (18)
argue that increasing N does not
necessaril y resolve this clifficul ty
when a large number of independent (predictor) variables (> 10)are
present. The df will be larger with
an increased N, which, taken by
i tsel f, increases power. However,
the type I error rate depends on the
number of statistical hypotheses,

January 1980, Volume 34, No.1

Downloaded From: http://ajot.aota.org/ on 05/14/2016 Terms of Use: http://AOTA.org/terms

and not on N. Even the potentially

higher power conferred by a large N
may be dissipated by a large k and
the inflated RZ that large k may
produce. The large number of independent variables in this study (16)
was necessary to include the subtests of the SCSIT battery. The
results of the chi-square and ANOVA
indicate a significant effect between
the two SCSIT response groups
based on SCPNT scores. The regression analysis was employed with
consideration of the large k as an
adjunctive procedure to further substantiate the findings of the previous sta tistica I ana I yses and to hel p
clarify the relation of individual
SCSITscores tonystagmus-responding ca teg-ories. The regression coefficienls and not the R Z value were
of primary importance in such an
analysis.
In thedata analytical spirit(21)of
this investigation, multiple regression analysis was felt to be the most
sophisticated and sensitive method
of providing relatwe Indications regarding which SCSIT subtests were
the best predictors of hyper-responsive PRN. In order to accomplish
this, the individual regression coefficients for each of the SCSIT subtests were mathematically converted
to beta weights. (Beta weights can
be though t of as the regression coefficients that would have been obtained if the various regression coefficients were equal to each other in
terms of means and standard deviations.) The independent or predictor variable with the largest absolute beta weight is the best predictor
of the dependen t, or criterion, variable. The calculated beta weights
and their corresponding t-values of
the independen t varia bles for each of
the SCSITs appear in Table 2.
Respective regression equations
were also generated for the 45 sub-

Table 2
Beta Weights and t-Values tor SCSIT Scores ot Children with Excessive Prn

Absolute
Beta WI.

I-value

Alpha
Level

Motor Accuracy (R + L)

.5614

3.41

P < .01

Imitation ot Posture

.5017

3.01

P < .01

Bilateral Motor
Coordination

.4664

2.17

P < .05

Standing Balance
Eyes Closed

.2311

1.67

NS

Standing Balance
Eyes Open

.0679

.89

NS

Space Visualization

.3011

206

P < .05

Figure Ground

2291

191

NS

Position in Space

.3044

204

P < .05

Design Copy

.4129

2.81

P < .01

Kinesthesia

.0978

.92

NS

Manual Form
Perception

.1871

1.37

NS

Finger Identification

.0672

87

NS

Crossing the Midline

.1071

1.03

NS

Graphesthesia

.0410

.47

NS

Localization of
Tactile Discrimination

0601

81

NS

Right/Left Discrimination

2513

2.00

NS

SCSIT*

Double tactile stimulation was not routinely given to all sUbjects and was not included
in the analysis.

jects with normal SCPNT scores

(-1.0 to + 1.0 SD) and the 49 subjects
with depressed SCPNT scores
-1.0 SD), using normal and depressed SCPNT scores as dependen t
variables and SCSIT scores as independent variables. The R2 for the
normal SCPNT group was .0916,
indicating that SCSIT scores accounted for less than 10 percent of
the shared variance with normal

SCPNT scores. The RZ for the depressed SCPNT group was .2348,
indicating that SCSIT scores predicted 23 percent of the shared variance with depressed SCPNT scores.
Computation and comparison of
beta weights revealed that almost
the entire amount of variance for
this equation was dependent on the
"Standing Balance Eyes Closed and
Open" tests of the SCSIT. This

finding supports an earlier study in

which the standing balance tests
along with selected clinical observations were found to be related
to depressed SCPNT scores (10).
The difference in mean ages between the two groups, although not
statistically significant (t =1.55, p>
.10, df/l07), indicates that Group I
children tended to be younger than
those children in Group II. Children with relatively greater neuropsychological involvement are more
likely to be identified as having
learning difficulties at an earlier
age than those children with little
or minimal neuropsychological dysfunction. This fact was believed to
have contributed to the age difference between the two groups. A
Pearson product moment correlation was computed between PRN
duration and age. No relationship
was found (r = .16, p> .01).

Discussion and Conclusion

Measuremen t of PRN has been one
of the primary techniques used to
differen tia te children wi th vestibular processing dysfunction. Ayres
has hypothesized that differential
neurophysiological mechanisms
may be operating as causative factors in depressed and excessi ve PRN
(1, 16). Depressed PRN may result
from overinhibition of the vestibular nuclei-possibly through connections with the cerebellum. Excessive PRN has been hypothesized to
result from an insufficient amount
of inhibition from higher level cortical centers acting on the vestibular
nuclei and pontine reticular formation (16). Markham (22) has reported
experiments on animals and humans, which indicate that an ablation or lesion of certain cortical
structures significantly enhances or
prolongs vestibular nystagmus. He
concluded his review by stating,

The American Journal of Occupational Therapy

Downloaded From: http://ajot.aota.org/ on 05/14/2016 Terms of Use: http://AOTA.org/terms

43

"Most of these studies indicate that

cortical lesions actually enhance or
prolong vestibular nystagmus. This
may suggest that the vestibuloocular arc is released from higher
centers and supports the general
concept of the cerebral cortex exerting an inhibitory type of modulation on lower centers." (22, p 592).
Recently Takemori, Ono, and
Maeda ha ve demonstra ted tha t the
parietal lobe is of particular importance in the cortica I con trol of vestibular nystagmus (23). Nystagmographic studies of children with
overt cerebral dysfunction including developmental delay and cerebral palsy have revealed significantl y
longer PRN durations for these children than for normal controls (2427), suggesting reduced cortical regulatory control over vestibular nystagmus.
The information reported in
Table 2 indicates that those learning-disabled children exhibitingexcessive PRN durations display lower
scores on those Southern California
Sensory Integration Tests that require higher level integrated cortical functioning: Motor Accuracy,
Imitation of Posture, Design Copy,
Bila teral Motor Coordination, Space
Visualization, and Position in
Space. In other words, the above
tests of the SCSIT shared the most
variance with, or were the best predictors of, excessive PRN.
The findings of this study provide tentative support for the Ayres
assertion that learning-disabled children with excessive PRN display
"greater or more extensive neurological involvement" than learning-disabled children with normal
or depressed PRN (I, p 25). Inferences from this investigation and
related literature indicate that learning-disabled children with excessi ve
PRN (14 percent of this sample)

44

may suffer from subtle Central Nervous System dysfunction of cortical

orgin. However, as noted previously, the question of neuropsychological involvement in a learning-disabled population is a relative one. The relationship between
excessive PRN and degree of neuropsychological dysfunction found
in this study must be regarded as
tentative. The results of this investigation provide indications for
further research.

Acknow Iedgmen ts
Appreciation is expressed to the
staff and children of the East Tennessee Children's Rehabilitation Center, and particularly to Jane
Kittrell, OTR, for their assistance
and cooperation, and to Michael
Ottenbacher for assistance with computer analysis.
REFERENCES
1. Ayres AJ: Learning disabilities and the
vestibular system. J Learn Disabil
1218-29,1978
2. de Quiros J B, Schrager OL: Neuropsychological Fundamentals in Learning
Disabilities, San Rafael, CA: Academic
Therapy Press, 1978
3. de Quiros JB: Diagnosis of vestibular
disorders in the learning disabled. J
Learn Disabi/9:1, 50-58, 1976
4. Nauton R: The Vestibular System, New
York: Academic Press, 1975
5. Ayres AJ: Sensory Integration and
Learning Disorders, Los Angeles: Western Psychological Services, 1972
6. Ayres AJ: Deficits in sensory integration in educationally handicapped children. J Learn DisabiI2:160-168, 1969
7. deQuirosJB: Vestibular-proprioceptive
integration: Its influence on learning
and speech in children. In Proceedings
of 10th Interamerican Congress of
Psychology, Trillas, Mexico, 1967
8. Ayres AJ: The Effect of Sensory Integrative Therapy on Learning Disabled
Children. Pasadena, CA: Center for
Study of Sensory Integrative Dysfunction, 1976
9. Steinberg M, Rendle-Short J: Vestibular dysfunction in young children
with minor neurological impairment.
Dev Med Child Neural 19639-651,
1977

January 1980, Volume 34, No.1

Downloaded From: http://ajot.aota.org/ on 05/14/2016 Terms of Use: http://AOTA.org/terms

10.0ttenbacher K: Identifying vestibular

processing dysfunction in learning disabled children. Am J Occup Ther
32:217-221,1978
11. Stilwell J, Crowe T, McCallum LW
Post rotary nystagmus duration as a
function of communication disorders.
Am J Occup Ther 32:222-228, 1978
12. Cheek CW: Electronystagmography in
children with specific learning disabilities. Ann Arbor, MI: Diss Abstr Internat
31:2171A,1970-1971
13. Frank J, Levinson H: Dysmetric dyslexia
and dyspraxia: Synopsis of a continuing research project. Acad Ther 11 :2,
133-143,1975-1976
14. Frank J, Levinson H: Dysmetric dyslexia
and dyspraxia. JAm Acad Child Psychiatr 12:690-701,1973
15.0ttenbacher K, Short MA. Watson PJ:
Nystagmus duration changes of learning disabled children during sensory
integrative therapy. Percept Mot Skills
48:1159-1164,1979
16. Ayres AJ: Southern California Postrotary Nystagmus Test Manual, Los
Angeles: Western Psychological Services, 1975
17. Ayres AJ: Southern California Sensory
Integration Tests, Los Angeles: Western Psychological Services, 1972a
18.Cohen J, Cohen P: Applied Multiple
Regression/Correlation Analysis for the
Behavioral Sciences, New York: John
Wiley and Sons, 1975
19.5chatzoff G, Feinberg E, Tsao E: Efficient calculations of all possible regressions. Technometrics 10:769-779, 1968
20. Kerlinger FN, Pedhazur FJ: Multiple
Regression in Behavioral Research, New
York: Holt Rinehart & Weston, 1973
21. Tuckey J: The future of data analysis.
Ann Math Stat 33:1-67, 1962
22. Markham, CH: Descending control of
the vestibular nuclei. Progr Brain Res
37589-600, 1973
23. Takemori S, Ono M, and Maeda T:
Cerebral contribution to the visual suppression of vestibular nystagmus. Arch
Oto/arynga/1 05:579-581, 1979
24. Torok N, Perlstein MA: Vestibular findings in cerebral palsy. Ann Otol Rhinal
LaryngoI71:51-67,1962
25. Chee F, Kreutzberg J, Clark D: Semicircular canal stimulation in cerebal
palsied children. Phys Ther 58:10711075, 1978
26. Kanter RM, Clark DL. Allen LL, Chase
MF: Effects of vestibular stimulation on
nystagmus response and motor performance in the developmentally delayed infant. Phys Ther 56:414-421, 1976
27. Rogos RC: Clinically Applied Vestibular Stimulation and Motor Performance
in Children with Cerebral Palsy, Master's Thesis. Columbus, OH: Ohio State
University, 1976