Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

review ARTICLE

Exploring Visual Perception Among Children With Developmental

Disability: A Scoping Review
Khairul Anam Md Yakup1,2, Lilyana Davina David1,3, Norzie Azlaili Pudzi1,4, Anis Hidayu Abd Shukor1,5,
Mohamad Qayum Mohamad Sabri1 ,Akehsan Dahlan1
1
Centre of Occupational Therapy, Faculty of Health Sciences, Universiti Teknologi MARA (UiTM), UiTM Kampus Puncak Alam,
42300 Bandar Puncak Alam, Selangor, Malaysia
2
Klinik Kesihatan Tandek, Peti Surat 421, 89108 Kota Marudu, Sabah, Malaysia
3
Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor, Malaysia
4
Hospital Putrajaya, Jalan P9, Present 7, 62250 W.P. Putrajaya, Malaysia
5
Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia

ABSTRACT

This scoping review is guided by its research question to explore an overview of the domains assessed and the as-
sociated variables of occupational therapy visual perception (VP) assessment among children with developmental
disabilities (DD). Articles that provided relevant information on both VP assessment and children with DD were
included in this review. Pertinent studies that were published from the year 2000 to 2021 were included. Twenty
articles met inclusion criteria. The findings highlighted eight domains of VP assessed in children with DD: (i) visual
memory; (ii) sequential memory; (iii) form constancy; (iv) visual closure; (v) figure-ground; (vi) visual discrimination;
(vii) spatial relation; and (viii) position in space. VP assessment explored the visual perception skills of children with
DD as individuals and as students. This scoping review mapped the utilization of VP assessment by an occupational
therapist to guide clinicians when exploring suitable VP assessment for children with DD.
Malaysian Journal of Medicine and Health Sciences (2022) 18(8):397-408. doi:10.47836/mjmhs18.8.49

Keywords: Visual perception, Assessment, Occupational therapy, Development disability

Corresponding Author: motor-reduced visual perception (purer VP) and motor-

Akehsan Dahlan, PhD enhanced visual perception (also known as visual-motor
Email: [email protected] integration).
Tel: +603-32584380
VP ability is one of the fundamental skills required
for children’s everyday activities (4,5). Education,
INTRODUCTION activities of daily living (ADL), play, leisure, and social
participation may all be affected if these skills are
Visual perception (VP) was defined as the ability to disrupted (6). A typically developing child, for example,
receive, recognize, interpret, and elaborate on visual may struggle with activities of daily living such as using
stimuli elicited by things and events (1). Its entirety is a mirror to comb hair, putting toothpaste to the brush,
responsible for the reception (sensory functions) and wearing clothes, and tying shoes (7).
cognition (specific mental functions) of visual stimuli
(2). Sensory function is the process of obtaining and Prior studies have shown that VP skills in children
organizing information from the environment. In with developmental disabilities (DD) are significantly
contrast, specific mental functions allow for organizing, impaired compared to typically developing children
structuring, and interpreting visual inputs, giving (8–12). According to Olusanya et al. (13), occupational
meaning to what is seen (2). When the two processes limitations produced by abnormalities of the growing
work together, individuals can comprehend what they nervous system throughout infancy and childhood are
see, and both functions are essential for functional known as developmental disabilities. These limitations
vision, which contributes more significant help in manifest themselves as developmental milestone
performing daily living activities. Brown (3) suggested delays or dysfunction in multiple domains, such
that VP consisted of two interconnected processes: as cognition, motor skills, vision, hearing, speech,

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and behavior, throughout infancy and childhood

(13). Sensory impairments (hearing and vision loss),
epilepsy or seizures, cerebral palsy (CP), attention
deficit hyperactivity disorder (ADHD), autism spectrum
disorder (ASD), intellectual disability (ID), or other
learning disorders (LD) are common in these children
(13).

Current studies by Chi and Lin (9) discovered a

relationship between self-care performance and VP
skills among children with ASD. In addition, in children
with CP, the VP was related to mathematics ability (10)
and ADL performance (14). In comparison, Jung et al.
(15) found that sensory processing may be a hallmark
of children with ADHD who have VP problems. Other
than that, there were also studies indicating that children
with Down’s syndrome (DS) (12), Developmental
Coordination Disorder (DCD) (16), and unique learning
disability (SLD) (17) perform significantly worse on VP
abilities.

Occupational therapists recognize their unique skills in

Figure 1: PRISMA flow diagram for the scoping
VP evaluation and intervention with children (18). Based
on research and philosophy such as family-centered
data, and (5) Collating, summarizing and reporting the
care and the World Health Organization’s International
result as shown in Figure 1
Classification of Functioning, Disability, and Health
(ICF; 19), occupational therapists’ approaches have
Identifying the Research Questions
grown and altered (20). These frameworks have led
The research question guiding this scoping review is,
many occupational therapists to shift away from
“What were the domains assessed and the associated
impairment-based interventions aimed at correcting
variables with VP assessments?”
the child’s deficits at the body structure and function
level, and instead focus on improving functional activity
Identifying Relevant Studies
performance and participation, as well as partnering with
Relevant studies were identified by searching through
parents to deliver therapy embedded in daily life (21). As
the following database, including Web of Science,
a result, occupational therapists must use solid clinical
Medline, Scopus, and ProQuest, using the keywords
reasoning to link the child’s occupational performance
visual perception, assessment, occupational therapy,
deficits to the fundamental factors associated with VP.
and developmental disability. The articles included in
the review were the title, keywords, or abstract of the
Since numerous studies suggest that children with DD
English-language source to provide relevant information
have VP impairment that can affect their daily living
on both VP and DD. All peer-reviewed articles, non-
skills, school performance, play, leisure, and social
peer-reviewed sources, and thesis were screened for
participation (4,7,22). However, there is inconsistency
potential inclusion. If the source did not include DD
in selecting and administering VP evaluation tools for
by name, it had to include reference to the diagnoses
this population. Recently, only one systematic review
associated with DD (e.g., cerebral palsy, Down
exists focusing on VP tools for children with hemiplegia
syndrome, dyslexia, autism spectrum disorder, learning
(23). Schneck (2) also emphasized that visual perception
disability, and attention deficit hyperactivity disorder).
is one of the least understood areas of evaluation and
Sources that addressed only the VP for the normal
treatment. Hence, this scoping review aimed to provide
population of children were excluded. Four reviewers
an overview of the available assessment used to address
(AH, KA, LD, NA) independently reviewed 945 titles
the VP skills of children with DD. In addition, it mapped
and abstracts. The process was elucidated in Fig.1.
the utilization of the VP assessment in children with DD.
Selection of Studies
METHOD
Records were included when they were available in
English or translated to English. Evaluation tools that
This scoping review was reported by using the (PRISMA-
assessed VP in DD children between 2000 until 2021
SCR) (24) and guided by a framework as recommended
were included. Participants in the study had to present
by Arksey and O’Malley (25) that comprises five stages:
with any DD at the start of the study. Studies on the
(1) Identifying the research question, (2) Identifying the
VP tools done on the non-developmental disabled
relevant studies, (3) Study selection, (4) Charting the
population were excluded. Meta-analysis was also

398 Mal J Med Health Sci 18(SUPP8):397-408 June 2022

considered as long as these studies adhered to the charting to identify and extract the domain and the
inclusion criteria. associated variables with VP assessments (26,27).

Charting the Data Collating, Summarizing and Reporting the Results

The charting of data was made from all captured The content analysis focused on the domain and the
information relating to the author(s) and year of associated variables with VP assessments assessed
publication, location of the study, study aims and within the DD population. Four reviewers (AH, KA,
purpose, study population and sample size, study LD, NA) independently completed the data extraction,
methodology, domain, and the associated variables with KA ensuring accuracy and consistency while
with VP assessments that related to the scoping review resolving conflicts across reviewers. AH, KA, LD, and
question. An analytic approach was used during data NA conducted the content analysis and refinement.

Table I: Summary of the articles.

Con-
tribu-
Population of the
Study tion
Author(s) studies/ sample Visual Perception Instruments Summary of findings
design in
size/ Country this
study
Auld et al. Systemat- Cerebral pal- 1. Test of Visual Perceptual Skills (TVPS) DTVP and MVPT demonstrate the 1
(2011) ic review sy-hemiplegia strongest clinimetric properties and
2.Motor-Free Visual Perceptual Test (MVPT) recommended for clinical practice.
Australia
3. Developmental Test of Visual Perception
(DTVP).
Belloc- Longi- Dyslexics (n=20) Developmental Test of Visual Perception Dyslexics showed lower motor-re- 1, 3
chi et al. tudinal version 2 (DTVP-2) duced VP and visual-motor integra-
(2017) study Typical tion skills which were associated in
learning to read.
developing child
(n=40)

France
Berelowitz Cross Cerebral palsy The Test of Visual Perceptual Skills 3rd ed. All the subtypes of CP were found 1, 2
& Franzsen sectional (n=80) (TVPS-3) to present with VP impairments. No
(2021) study significant differences were found for
South Africa VP based on GMFCS levels.

Bischof et Cross Spastic diplegia Beery-Buktenica Developmental Test of There were significant correlations 2, 3
al. (2012) sectional (n=40) Visual Motor Integration (VMI) between VIS and VMI scores and
study school grade appropriateness in
South Africa children with spastic diplegia.

Chen et al. Experi- Developmental The Test of Visual Perception Skills, third The multimedia visual perceptual 1
(2013) mental delays (n=64) edition (TVPS-3) group training program was more
study effective for improving VP than was
Taiwan multimedia visual perceptual indi-
vidual training program.
Chi & Lin Cross Autism Spectrum 1.The Test of Visual Perceptual Skills-Third Positive correlations were found 1, 2
(2021) sectional Disorder (n=66) Edition (TVPS-3) between self-care performance and
study VP ability in children with ASD.
Typically 2.The Developmental Test of Visual Per-
developing child ception-Third Edition (DTVP-3)
(n=66),

Taiwan
Critten et Cross Cerebral palsy 1.BPVS-III Receptive vocabulary and VP abili- 1, 3
al. (2018) sectional (n=32) 2.Mathematics Oral test ties were the best predictors of math-
study  3.British Ability Scales 3rd edition (BAS3)  ematical ability in the CP group.
Typical develop- Matrices
ing child (n=32). 4.Mathematics written paper,
5.Mental Rotation Task
United Kingdom 6.Working Memory Test Battery (WMTB-C)
Block Recall7. TVPS-3 (R)
Cuomo Cross Learning disabili- 1.Test of Visual Perceptual Skills—Revised There were a relationship between 1, 3
(2001) sectional ties (n=11) TVPS-R and handwriting perfor-
study 2. Handwriting Checklist. mance among children with LD.
United States

CONTINUE

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Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

Table I: Summary of the articles.(Cont.).

Con-
Population of the tribu-
Study
Author(s) design studies/ sample size/ Visual Perception Instruments Summary of findings tion
Country in this
study
1. The Developmental Test of Visu-
Cerebral palsy (n=10) al-Motor Integration
Desai Cross The findings shows that low VMI
Typical developing
& Rege sectional child (n=40), (VMI) (Beery, 1997) scores, his handwriting skills will be 3
(2005) study affected.
2. The Modified Scale of Children’s
India Readiness In Printing (SCRIPT)
Autism (n=32) There was a strong relationship
1.Bruininks Oseretsky Test of Motor between perception, VP, and self-
Typical developing care and social function according
Cross Proficiency (BOTMP)
Günal et al. child (n=30) to Paediatric Evaluation of Disability
(2019) sectional Inventory (PEDI) of children with 2
study 2.The Lowenstein Occupational Ther- autism. However, no relationship of
apy Cognitive Assessment (LOTCA) VP measured by LOTCA and mobility
Turkey as determined by PEDI.

1. Assessment of Motor and Pro-

cess Skills (AMPS),
Cerebral palsy
(n=101) 2. Jebsen–Taylor Test of Hand Process skills of ADL are related to
Cross Function (JTTHF) VP ability and dominant upper limb
James et al.
(2015 sectional unimanual capacity. 2
study 3. Assisting Hand Assessment
(AHA)
Australia
4. (4) Test of Visual Perceptual
Skills, 3rd edition (TVPS-3)
1. Korean Developmental Test of
Visual Perception-2 The results reflect that decreased sen-
ADHD (n=47),
Jung et al. sory processing may be a hallmark of
(2014) Cross children with ADHD who have VP
2. Short Sensory Profile
sectional problems. 1, 2
study
3. Kiddie-Schedule for Affective Dis-
Korea orders and Schizophrenia-Present and
Lifetime Version-Korean Version
1. The Bender-Gestalt Test-Sec-
Autism Spectrum ond Edition (BG II)
Disorder (n=22)
2. The Beery-Buktenica Devel-
opmental Test of Visual-Mo-
tor Integration, 5th Edition The results indicated VP was the
Cross
Oliver best predictors of reading ability,
(2013) sectional Typically developing (VMI-V)
writing, and math skills among ASD 1, 2, 3
study child (n=23) childrens.
3. The NEPSY Second Edition
(NEPSY-II)

United State 4. The Test of Visual Perceptual

Skills-3 (TVPS-3)

Typical developing
Prospec- children (n=30) Visual-spatial perception by using
Surkar & tive, LOTCA instruments is one of the
1.Loewenstein Occupational Therapy
Writer parallel Children diagnosed Cognitive Assessment Scale (LOTCA) contributory factors for gross motor 1, 2
(2010) design with epilepsy (n=30) dysfunction such as balance in chil-
study dren with epilepsy.
India

1.Motor-Free Visual Perception Test–

Cerebral palsy (n=52) Revised (MVPT–R)
Tsai, Lin, The results indicate that the total
Cross
Liao, & scales of the MVPT–R and TVPS–R
Hsieh sectional can be used at the individual or 1
study
(2009) group level of children with CP.
Taiwan 2.The Test of Visual–Perceptual Skills–
Revised (TVPS–R)
Vetrayan et The result revealed that the school
Cross Autism (n=20),
al. (2015) Developmental Test of Visual Percep- function of autistic children has a
sectional tion: Second Edition (DTVP-2) significant relationship with their VP 1, 3
study Malaysia and imitation performance.

CONTINUE

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Table I: Summary of the articles (Cont.).

Con-
Population of the tribu-
Study
Author(s) design studies/ sample Visual Perception Instruments Summary of findings tion
size/ Country in this
study
Wan et al. Cross Down syndrome Test of Visual Perceptual Skill-Third Significant between-group differenc- 1
(2015) sectional (n=70) Edition (TVPS-3) es in TVPS-3 were observed between
study either DS or ID and TD groups.
Typical develop- There was no significant difference
ing child (n=70) on TVPS-3 between DS and ID
groups.
Intellectual dis-
abilities (n=40)

Taiwan

Gajre Mona et Obser- Specific Learning 1. The test of visual perceptual skills The result shows that VP skills were 1
al. (2015) vational disability (n=99) 3rd edition (TVPS-3) affected significantly among all SLD
prospec- categories (dyslexics, dysgraphics, and
tive study 2. The developmental test of visual dyscalculics).
motor integration tests (VMI)
India

Wuang & Tsai Cross Williams syndrome Test of Visual Perceptual Skill, Third Cognitive level (IQ) is strongly related 1, 2, 3
(2017) sectional Edition (TVPS-3) to all visual perceptual. The correla-
study (n =38) tions between the TVPS-3 scores and
the VABS-C and SFA-C subdomains
Taiwan (activity participation measures) are
mostly in the moderate range.

Prunty et al. Cross Developmental 1. The Beery-Buktenica Develop- There are significant effects on the 1, 3
(2016) sectional Coordination mental Test of Visual-Motor VMI, as the DCD group had poorer VP
study Disorder (n=28) Integration, (VMI) skill compared to typically developmen-
tal children. No significant correlation
Typical developing 2. Test of Visual Perceptual Skill between TVPS subtest and any of the
children (n=28) (TVPS) handwriting measures.

Australia
1
domains of visual perception assessed, 2visual perception as an individual, 3visual perception as a student

Table II: Domains of visual perception assessed and its associated variables.
Visual Cognitive Functions Object Perception Spatial Perception

Domain assessed Visual Memory Sequential Visual Dis- Form con- Visual Closure Figure Spatial Rela- Position
Memory crimination stancy Ground tion in Space

Attention Deficit (15) (15) (15) (15,35) (15)

Hyperactivity Disor-
der (ADHD)

Autism Spectrum (9) (9)) (9,33) (9,34) (9,34) (9,34) (9,34) (34)
Disorder (ASD)

Cerebral Palsy (10,23,31,32) (10,23,31,32) (10,23,31,32) (10,23,31,32) (10,23,31,32) (10,23,31,32) (10,23,31,32) (23)

Developmental (28) (28) (28) (28) (28) (28) (28)

Delay (DD)

Down Syndrome (12) (12) (12) (12) (12) (12) (12)

Dyslexia (17) (17) (17) (8,17) (8,17) (8,17) (8,17) (8)

Dysgraphia (17) (17) (17) (17) (17) (17) (17)

Dyscalculic (17) (17) (17) (17) (17) (17) (17)

Epilepsy (35)

Intellectual Dis- (12) (12) (12) (12) (12) (12) (12)

ability

Learning Disability (17,29) (17,29) (17,29) (17,29) (17,29) (17,29) (17,29)

Williams syndrome (30) (30) (30) (30) (30) (30) (30)

Developmental Co- (16) (16) (16) (16) (16) (16) (16)

ordination Disorder

CONTINUE

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Table II: Domains of visual perception assessed and its associated variables.(cont.)

Visual Cognitive Functions Object Perception Spatial Perception

VP as an individual VP as a
student
Senso- Visual Gross Self-Care Com- IQ Mo- Social Read- Handwriting Math- School School
ry Pro- Motor Motor mu- bility Func- ing Ability emat- Func-
cessing Inte- nica- tion Abil- ical tion Grade
gra- tion ity Ability
tion

(15) (33) (30,31,35) (9,11,14,30) (30) (30) (11) (11,30) (8,33) (16,29,33,36) (10,33) (30,34) (37)

RESULTS
Domain of Visual Perception Assessed
Twenty articles were eligible for this study. The summaries Visual Cognitive Functions (VCF)
of the selected articles were presented in Table I, and VCF were assessed in children with DD (28), ASD
the domains of VP assessed and its associated variables (9), LD (29), DCD (16), WS (30), and CP population
were shown in Table II. (10,23,31,32) respectively. Meanwhile, one study
assessed only sequential memory on the ADHD
Overview of the studies population (15) and another one only assessed visual
1. Study design discrimination in the ASD population (33).
There were fifteen cross-sectional studies, two
experimental studies, one systematic review, longitudinal Studies assessed on Object Perception (OP)
study, and prospective observational study, reviewed OP were assessed in children with CP (10,23,31,32),
respectively. DD (28), ASD (9, 34), LD (29), DCD (16), and WS (30),
DS and ID (12), dyslexia, dysgraphia and dyscalculia
2. Population and sample size population (8,17). Only one study was found limited to
The highest population and sample size is CP (n=315) assessing form constancy and figure-ground in children
followed by LD (n=130), and ASD (n=118). with ADHD (15).

3. Location and setting Studies assessed on Spatial Perception (SP)

The studies were mostly conducted in Taiwan (n=5) Spatial Relation were assessed in children’s with
followed by Australia (n=3), and India (n=3). The CP (10,23,31,32), ASD (9,34), ADHD (15,35),
selected studies ranged from the year 2000 until 2021. dyslexia (8,17), LD (17,29), DD (28), WS (30), DCD
(16), epilepsy (35), DS and ID (12), dysgraphia and
4. Visual perception assessment dyscalculia populations (17). Position in space were
Various standardised assessments on VP were utilised: assessed in ADHD (15), ASD (34), CP (23), and dyslexia
1) Test of Visual Perceptual Skills (TVPS) (n=12), 2) (8) population respectively.
Beery-Buktenica Developmental Test of Visual-Motor
Integration (VMI) (n=5) , 3) Motor-Free Visual Perceptual Visual Perception as an Individual
Test (MVPT) (n=2), 4) The Developmental Test of Visual Sensory processing
Perception (DTVP) (n=5), and 5) The Lowenstein The results reflect that decreased sensory processing
Occupational Therapy Cognitive Assessment (LOTCA) may be a hallmark of children with ADHD who have
(n=2). VP problems and will have difficulties performing tasks
such as matching shapes or objects, or tasks containing
5. Main findings unfamiliar stimuli or subtle discriminations (15).
There were three major domains of VP assessed in
children with DD: (i) visual cognitive function (visual Visual-motor integration performance
memory, sequential memory, and visual discrimination), Oliver (33) revealed TVPS-3 as the most significant
(ii) object perception (form constancy and figure-ground), predictor of visual-motor integration performance in
and (iii) spatial perception (spatial relation and position children with ASD.
in space). The associated variables were divided into
two groups: (i) VP as individuals (sensory processing, Gross motor dysfunction
visual-motor integration, gross motor dysfunction, self- Surkar and Writer (35) reported VP is one of the
care, communication, intelligence quotient, social contributory factors for balance in children with
function, and mobility) and (ii) VP as students (reading epilepsy. Wuang and Tsai (30) study highlighted an
ability, handwriting ability, mathematical ability, school association between VP and motor skills component
function, and school grade). in activity participation measures (VABS-C) in children

402 Mal J Med Health Sci 18(SUPP8):397-408 June 2022

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with WS. Contrarily, Berelowitz and Franzsen (31) Mathematical ability

found no significant difference between GMFCS levels TVPS-3 (R) were the best predictors of mathematical
and TVPS-3 in children with CP. ability in the CP group (10). Besides, Oliver (33) also
found that VMI-V can predict math skills in ASD
Self-care performance children.
Chi and Lin (9) recorded correlations between self-care
performance and VP ability in children with ASD. Gunal School function
et al. (11) revealed a relationship between VP and self- Imitations in school functions among children with
care of children with ASD. According to James et al. ASD have a relationship with motor-reduced VP &
(14), ADL performance is related to visual sequential visual-motor integration in the DTVP-2 (34). Besides
memory and visual closure abilities among children investigating the VP functioning in school-aged children
with CP. Moreover, difficulties in motor skills and with WS, Wuang and Tsai (30) found the correlations
visuospatial construction challenged daily living skills between the TVPS-3 and the SFA-C.
of the children with WS (30).
School grade appropriateness
Communication Bischof, Rothberg, & Ratcliffe (37) found that the school
Wuang and Tsai (30) stated all VP subtypes in TVPS-3 grade appropriateness in children with spastic diplegia
correlate with the communication domain in VABS-C can be predicted from VP assessment.
among children with WS.

Intelligence Quotient (IQ) DISCUSSION

Cognitive level (IQ), measured by WISC-III, is strongly
related to all VP domains (TVPS-3) among children with This scoping review aimed to provide an overview
WS (30). of the VP assessment used among children with DD.
Our findings indicate a global perspective on the VP
assessment used among children with DD. As most of
Social functions the studies were cross-sectional studies, the information
Gunal et al. (11) identified a relationship between VP gathered from a cross-sectional study in this review
(LOTCA) and social function (PEDI) of children with can be used as a springboard for using a more robust
ASD. Besides, all VP subtypes in TVPS-3 correlates with design to support the initial findings (38). Other than
the socialisation skills domain in VABS-C of children that, findings also showed assessments being used by
with WS (30). the occupational therapist to evaluate VP in children.
The Test of Visual Perceptual Skills dominated current
Mobility literature. It contradicts the earlier assertion that the
Gunal et al. (11) found no relationship between VP Developmental Test of Visual Perception Second Edition
measured by LOTCA and mobility items in PEDI for (DTVP-2) was the most utilised assessment among
children with ASD. occupational therapists to measure VP (39).

Visual Perception as a Student Domains of Visual Perception Assessed

Reading ability Attention Deficit Hyperactivity Disorder, Autism
Bellocchi et al. (8) found that children with dyslexia have Spectrum Disorder, Down Syndrome and Intellectual
lower motor-reduced VP and visual-motor integration Disability Population
skills than typical readers, which are associated with Previous literature mentioned that comorbidity with
reading, and point out the DTVP-2 as the best VP ADHD has been dramatically studied (40), and changes
assessment to indicate the reading abilities of dyslexics’ in VP have been commonly described in people with
children. Furthermore, Oliver (33) found that the VP ASD (41). To our knowledge, a study by Wan et al. (12)
skills were the most significant indicators of reading was the first study to use standardised psychometric
competency in ASD. testing to assess overall VP functions in DS, as previous
research has only focused on the significant deficiency
Handwriting abilities in language ability (42). Meanwhile, Giuliani, Favrod,
Cuomo (29) found that specific VP subtests in TVPS-R Grasset, & Schenk (43) mentioned how VP is affected
significantly affected handwriting performance in among the ID population. Therefore more research may
children with LD. Desai and Rege (36) and Oliver be required to measure VP in those four populations
(33) suggested VMI was the best predictor of reading mentioned (ASD, ADHD, DS, and ID).
competency in ASD and CP children. However, Prunty
et al. (16) found no significant correlations between the Cerebral Palsy and Epilepsy Population
TVPS and any handwriting measures in the DCD group. According to Ego et al. (44), there was still a scarcity
of data on lesion characteristics related to VP. Still, the

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severity of brain damage may influence the severity of been a continuing dispute in the empirical literature
VP impairment. Besides that, in a study by Surkar and concerning the association between motor-reduced
Writer (35), only domain spatial perception (spatial and motor-enhanced VP skills (3). A previous study
relation) was assessed using LOTCA. A possible reason provides evidence that motor-reduced VP skills and
is that perceptual impairment in epilepsy patients is motor-enhanced VMI skills are interdependent systems
most likely caused by structural damage to the prefrontal (3) which is consistent with the occupational therapists
cortex and dorsal stream (45). As a result, assessing the VP conception, the Warren model of the hierarchy of VP
visual perception domain in these two populations is (50,51), and VP FOR (2,22).
preferable based on the severity and part of the brain
affected. Gross motor dysfunction
VP contributes to gross motor dysfunction, such as
Williams Syndrome and Developmental Coordination balance problems (11,30,35). Gunal et al. (11) recorded
Disorder Population that the BOMPT determined the lower motor function
The downside of both articles (16,30) is the small sample related to the visuospatial deficit assessed by LOTCA
size. Therefore, having a bigger sample size is suggested for children with autism. However, Berelowitz and
to offer a broader range of possible data and forms a Franzsen (31) discovered no significant difference in
better picture for analysis (46). GMFCS levels on any composite scores on the TVPS-
3 in children with CP. These findings are consistent
Learning Disability (Dyslexia, Dysgraphia, and with Hamid, Mostafa, Saeid, Hojjat Allah, and Akbar
Dyscalculia) (52), who discovered that the severity of gross motor
The auditory and VP were discovered to impact functioning had no direct impact on the VP skills of
mathematical abilities substantially (47). In Gajre Mona children with CP.
et al. (17), below average age scores in discriminating,
spatial perception, but not visual memories were Self-care performance
obtained in dysgraphia, which contradicted a prior VP abilities impact self-care performance among children
study by Dhingra et al. (47). This might have happened with DD (9,11,14,30). Children with autism have
because the dysgraphia has more issues with auditory substantial perception issues, which cause disability by
discriminations, along with visual discriminations, affecting self-care (9,11). However, it is reasonable to
figure-ground discriminations, and perceptual scores believe that a limited motor planning process capability
(47). TVPS and VMI did not measure auditory factors, could impact the performance of motor integration-
and therefore more research may be required to assess related daily living skills (14,30,53,54). The challenges
the relationship between VP and auditory factors in this in performing daily living activities such as wearing
population. clothes, personal hygiene, and mobility are exacerbated
by the motor challenges of children with motor planning
Visual Perception as an Individual impairment such as children with CP and WS, which
Sensory processing are compounded by their difficulty in visuospatial
Sensory processing has an impact on VP performance construction (14,30).
(1,15,48). The central part of the occupational therapy
literature on VP comprises contributions from therapists Communication
who use sensory integration or cognitive approaches VP domain in the TVPS-3 correlates with the
(49). Surprisingly, only one paper was discovered communication domain in VABS-C among children with
showing decreased sensory processing may be a WS (30). However, there is minimal literature that can
distinguishing feature of children with DD who have support these findings. ID, hearing loss, an expressive
VP difficulties (15). Impaired sensory processing may language impairment, psychosocial deprivation, autism,
be a defining feature of ADHD children who have VP elective mutism, receptive aphasia, and CP can all cause
issues. According to Vlok et al. (49), this scope indicated a delay in speech development (55). Thus, it is unclear
other associations between VP and sensory integration how VP could cause communication problems among
might be investigated in children with DD. However, children with DD.
the therapeutic potential of eye movements as warm-up
exercises before visual perceptual tasks, task adaptation Intelligence Quotient (IQ)
to improve particular eye movements, and cognitive Cognitive level, measured by WISC-III, is strongly related
techniques as fundamental components of visual to all VP domains measured by the TVPS-3 among
perceptual programs have not been well investigated. children with WS (30) may have inferred that most
people with DD experienced cognitive deficiencies
Visual motor integration performance on tasks requiring precise visuospatial perception and
VP ability was the most significant predictor of visual- memory (1,56).
motor integration performance in children with autism
(33). However, the outcome was less explored in Social functions
other DD literature. For the last few decades, there has There is a strong relationship between VP and social

404 Mal J Med Health Sci 18(SUPP8):397-408 June 2022

function among children with autism and WS (11,30). practice is ubiquitous and problematic (64–66).
The significance of vision in allowing new-borns Mathematical ability
to participate in social interactions has long been Visual short-term memory, visual reasoning, and mental
acknowledged (22). Emotions are communicated rotation in the TVPS-3 (R) were the best predictors of
chiefly through facial expressions (57). In the joint mathematical ability in the CP group (10). Oliver (33)
attention paradigm, a new-born can shift attention from found that VMI-V can be used to predict math skills in
one person to another or an item of common interest, autistic children. However, these findings are still limited
by the end of the first year, also known as the social for other conditions and should be discovered in further
imitation (D’Entremont, 1997). When identical objects research for atypical and typically developing children.
are accessible, toddlers copy a peer’s action on an object
(22). However, additional research should be done School function
to understand the relation between visual perception Autism children’s low performance on school-related
function and social function among different conditions functional activities is linked to VP skills, particularly
of atypical children. in the Motor-reduced VP function (34). It is critical to
recognize which VP dysfunction among children with
Mobility DD causes low functional task performance, such as
VP skills influence functional mobility (59). We perceive academic and social functions.
our surroundings utilising all of our senses simultaneously,
resulting in a complex multimodal representation of School grade appropriateness
space. This multimodal representation can be used Bischof et al. (37) discovered a relation between VP
to move around our surroundings, interact spatially and school grade appropriateness among spastic
with them, locate things, and estimate their speed and diplegic children. Nevertheless, there is minimal
relative location in space. In turn, this representation research regarding this correlation. Visual impairments
is also influenced by our bodily sensations (59,60). can have a negative impact on school achievement
Even though ASD is linked to abnormal perceptual and (8,10,16,29,30,33,34,36). Hence, these imply that it
sensory symptoms, surprisingly, Gunal et al. (11) found could also result in the child’s school grade.
no relationship between VP and mobility in children
with autism. After reviewing the findings, the authors found a massive
need for more study on occupational therapy assessments
Visual Perception as a Student for VP in people with various DD. Our results also
Reading ability indicate that less paper explored these issues according
The VP assessment is a suitable tool to explore the to specific types of DD. Thus, careful interpretations
relationship between VP and reading (8,33). However, are warranted. In addition, it is recommended such
consideration needs to be highlighted by the examiner studies also should look into a broader range of DD,
before exploring these connections. The level of IQ such as Angelman syndrome, Fragile X syndrome, Fetal
score might as well be the leading cause of children’s Alcohol Syndrome, and others. A suitable sample size,
difficulty in reading and need longer time to read a appropriate assessment tools, and more robust methods
simple sentence (61). Many neurodevelopmental, are also needed to conclude this review better.
psychiatric, and medical disorders co-occur with ID,
especially communication disorders, LD, CP, DS, Future studies may also explore the association of VP
epilepsy, and various genetically transmitted conditions with play as less focus was given on these areas in
(56). However, no studies were found to explore the children with DD. Lynch & Moore (67) suggested that
relationship between VP abilities and reading skills occupational therapy prioritise play among children
among children with dysgraphia and dyscalculia. with DD as it is their core role (68). Play activities need
a significant integration and execution of VP and fine
Handwriting abilities motor abilities (69). Therefore, exploring the association
Standardized assessments such as TVPS, TVPS-R, VMI of VP with play in children with DD is needed.
can be used to predict the handwriting ability of children
with DD (16,29,33,36). Other causes that influence LIMITATIONS
handwriting problems are motivation, behavior, fine
motor skills, gross motor function, coordination, Few databases were scoped, and non-English articles
language, reading, and spelling skills (62,63). According were excluded. Therefore, valuable anonymous data
to Prunty et al. (16), tests of VP do not appear to be that were not formally or yet published may exist. In
sensitive to or related to handwriting difficulties in addition, this scoping review covered a wide variance
children with DCD. More reading regarding this matter of the population with DD. Hence the conclusion made
needs to be considered in future studies, among other in this study shall be interpreted carefully. Furthermore,
conditions of DD. However, considering that none of because this paper is not intended to review the evidence
the goals listed in either handbook advise utilizing these of psychometric properties (i.e., validity and reliability)
tests in the context of handwriting, their application in and clinical utility of a VP assessment instrument (70),

Mal J Med Health Sci 18(SUPP8):397-408 June 2022 405

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

it is unclear whether or not occupational therapists use 8. Bellocchi S, Muneaux M, Huau A, Lévêque Y, Jover
those available instruments for children with DD is M, Ducrot S. Exploring the Link between Visual
consistent with best practice and evidence. Perception, Visual–Motor Integration, and Reading
in Normal Developing and Impaired Children
CONCLUSION using DTVP-2. Dyslexia. 2017;23(3):296–315.
9. Chi IJ, Lin LY. Relationship Between the
This scoping review successfully mapped the utilisation Performance of Self-Care and Visual Perception
of the VP assessment in children with DD. The scoped Among Young Children With Autism Spectrum
found three major domains assessed (visual cognitive Disorder and Typical Developing Children. Autism
function, object perception, and spatial perception) and Res. 2021;14(2):315–23.
two associated variables (VP as individuals and VP as 10. Critten V, Campbell E, Farran E, Messer D.
students) of VP assessments in children with DD. The Visual perception, visual-spatial cognition and
evidence suggested VP assessment can be conducted to mathematics: Associations and predictions in
explore the domain assessed and associated variables children with cerebral palsy. Res Dev Disabil.
considering various ranges of DD. Hence, the results of 2018;80(May):180–91.
this study can potentially influence the future orientation 11. Günal A, Bumin G, Huri M. The Effects of Motor and
of the occupational therapy profession, which may Cognitive Impairments on Daily Living Activities
guide clinicians when exploring suitable VP assessments and Quality of Life in Children with Autism. J
for children with a DD. Occup Ther Sch Early Interv. 2019;12(4):444–54.
12. Wan YT, Chiang CS, Chen SCJ, Wang CC, Wuang
ACKNOWLEDGMENTS YP. Profiles of visual perceptual functions in Down
syndrome. Res Dev Disabil. 2015;37:112–8.
The authors would like to thank the Faculty of Health 13. Olusanya BO, Davis AC, Wertlieb D, Boo NY, Nair
Sciences, Universiti Teknologi MARA, Puncak Alam MKC, Halpern R, et al. Developmental disabilities
Campus for the facilities and support. among children younger than 5 years in 195
countries and territories, 1990–2016: a systematic
analysis for the Global Burden of Disease Study
2016. Lancet Glob Heal. 2018;6(10):e1100–21.
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