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Development of the Sensory Processing Measure–School: Initial Studies of Reliability and Validity

KEY WORDS• pediatric• praxis• sensory integration• sensory processing• Sensory Processing Measure–School

(SPM–School)

Over the past 10 years, important changes have occurred in what is consideredto be best practice in occupational therapy in the schools (Muhlenhaupt, 2003;

Roley, Clark, Bissell, & Brayman, 2003; Swinth & Muhlenhaupt, 2004). Concur-rently, occupational therapists are increasingly being asked to evaluate schoolchil-dren to determine the impact of sensory processing difficulties on the child’s edu-cational performance. In response to this need, the Sensory ProcessingMeasure–School (SPM–School) was created.

Description of the SPM–SchoolThe SPM–School contains items related to sensory processing, praxis, and socialparticipation in seven school environments (classroom, recess, cafeteria, music, art,physical education, and bus), each of which are rated with a Likert scale. Each envi-ronment’s rating scale is completed by the appropriate staff member (e.g., class-room teacher, art teacher, lunchroom assistant), who has known the child for atleast 1 month. The tool’s purpose is to provide information to the educational teamabout the sensory facilitators of, and barriers to, successful functional performancein school by comparing and contrasting environments. It is recommended that allenvironments be completed; however, the tool may be used with the primary class-room teacher alone. The tool’s structure allows comparison within and across envi-ronments, between sensory processing categories, praxis items, and social partici-pation. These comparisons facilitate team discussions, which can identify or ruleout the sensory basis of social behavior as well as identify specific contextual com-ponents facilitating or inhibiting functional performance.

Heather Miller-Kuhaneck, MS, OTR/L, is Instructor,Sacred Heart University, Fairfield, CT.

Diana A. Henry, MS, OTR/L, is Owner, Author, andInstructor, Henry OT Services, Inc., on Ateachabout,www.ateachabout.com.

Tara J. Glennon, EdD, OTR/L, FAOTA, is Professorof Occupational Therapy, Quinnipiac University, Hamden,CT; and Owner, Centers for Pediatric Therapy, CT. Corre-sponding address: 23 Seaview Avenue, Milford, CT 06460;tara.glennon@quinnipiac.edu.

Keli Mu, PhD, OTR/L, is Assistant Professor, Depart-ment of Occupational Therapy, Creighton University,Omaha, NE.

OBJECTIVE. The history and development of the Sensory Processing Measure–School are detailed, andfindings of initial pilot studies are reported.

METHOD. Multiple reviews, focus groups, case studies, and two pilot studies were used to develop the earlyversions of the tool. Internal consistency and discriminatory ability were examined.

RESULTS. Internal consistency measured with Cronbach’s alphas ranged from .93 to .99 in the first pilotstudy and .70 to .99 in the second pilot study. Children who were typically developing were correctly classi-fied 92.3% of the time, and children with sensory issues were correctly classified 72% of the time.

CONCLUSION. Initial results suggest that the tool is reliable and valid and discriminates children with andwithout sensory processing issues. Further research is under way with larger samples.

Miller-Kuhaneck, H., Henry, D. A., Glennon, T. J., & Mu, K. (2007). Development of the Sensory ProcessingMeasure–School: Initial studies of reliability and validity. American Journal of Occupational Therapy, 61, 170–175.

Heather Miller-Kuhaneck, Diana A. Henry, Tara J. Glennon, Keli Mu

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Literature Review: Need for the SPM–School

The decade between 1995 and 2005 has seen two reautho-rizations of the law mandating occupational therapy prac-tice in the schools (the Individuals with Disabilities Educa-tion Act [IDEA]); the adoption of the Occupational TherapyPractice Framework (American Occupational Therapy Asso-ciation [AOTA], 2002); a return to our professional roots,with a greater emphasis on occupation throughout our pro-fession (AOTA, 1995; Canadian Association of Occupa-tional Therapists, 1991; Kielhofner, 2004); an increasedpublic awareness of sensory integration and sensory pro-cessing disorders; and the resultant changes in practice thatall of these other changes prompted. The ability of all chil-dren to access a free and public education has been posi-tively affected by occupational therapy services since thepassage of the Education for All Handicapped Children Actof 1975 (P.L. 94-142). However, the way that occupationaltherapists operate within the school environment, and thusthe tools that they require to successfully support children,have changed with the revisions of this original legislation.The IDEA of 1990 (P.L. 101-476) emphasized supportingchildren in the least restrictive environment, accessing gen-eral education, and providing an appropriate evaluation.The 1997 reauthorization of IDEA (P.L. 105-117) furtherillustrated the ideal evaluation process as multidisciplinary,specifically mandating that regular education teachers beinvolved in the evaluation and planning process. The mostrecent reauthorization of the IDEA (P.L. 108-448) in 2004,as well as the 2001 No Child Left Behind general educationlegislation (P.L. 107-110), emphasized that children requiresupport and specifically designed instruction to access andprogress in the general education curriculum and that earlyidentification and prevention are key factors to a child’s suc-cess. As a result of these legislative changes, a shift awayfrom a primarily diagnostic procedure has occurred in theeducational evaluation process. Rather, a process that isconsidered best practice identifies functional problems,considers how the child manages the general education cur-riculum, and focuses on the child’s educational needs so theteam can support performance within a variety of naturalcontexts.

Occupational therapists are urged to assess a person’stask performance within appropriate contexts, in collabora-tion with others, as opposed to measuring isolated skills ina testing situation (Baum & Christiansen, 2004; Dunn,2000; Law, Baum, & Dunn, 2000; Mancini & Coster,2004; Orr & Schkade, 1997; Stark & Sanford, 2004).Assessing the environmental aspects of occupational func-tioning and participation across school settings, and com-pleting these assessments via team collaboration, is now

considered best practice (Case-Smith, 1997; Clark &Coster, 1998; Clark & Miller, 1996; Kemmis & Dunn,1996; Swinth & Muhlenhaupt, 2004). This method bene-fits not only the student but also the occupational therapistand teachers. Therapists report feeling successful when theyare able to reframe a student’s behavior and help the teamto greater understanding (Case-Smith, 1997), teachers mayperceive greater occupational therapy contribution to stu-dent skill development as collaborative practices increase(Barnes & Turner, 2001), and students benefit from theeffectiveness of linking occupational therapy evaluation andintervention to the student’s academic goals (Kemmis &Dunn, 1996).

Children with poor sensory processing and praxis oftenhave difficulties functioning in the classroom environmentand can present challenges to educational team members asthey attempt to determine the cause of the child’s poor per-formance. If, as parent report indicates, between 5% and13% of all children may have sensory processing disorders(Ahn, Miller, Milberger, & McIntosh, 2004), a large num-ber of children attending school may have these difficulties.Although the relationship between poor sensory processingand educational performance has long been hypothesized(Ayres, 1972, 1979) and some supportive evidence exists(Parham, 1998), the sensory integration frame of referenceis used in the schools when a student’s sensory concernscontribute to significant, documented, educational difficul-ties (Roley, Clark, Bissell, & Brayman, 2003). With thatsaid, the sensory integrative frame of reference is frequentlyused in schools and reportedly is one of the predominantlyapplied approaches (Storch & Eskow, 1996). School-basedoccupational therapists report success when they are able toidentify an underlying cause for a behavior, often by usingthe sensory integration frame of reference (Case-Smith,1997); however, currently no tools are available to guidethem in this process.

Many of our current assessments do not readily providethe types of information we need, and the commonly usedtools that examine motor skills are not designed to examineeducational performance in context. The School FunctionAssessment (Coster, Deeney, Haltiwanger, & Haley, 1998),which allows comparison of functional abilities across schoolenvironments, does not specifically provide informationabout a child’s sensory processing and its impact on educa-tional performance. The Sensory Integration and PraxisTests (Ayres, 1989), an excellent diagnostic tool for sensoryintegrative dysfunction, does not specifically examine edu-cational performance in context, whereas parent or care-giver questionnaires that examine sensory processing havenot been designed for school use. Therefore, no publishedtools are available to assist the school-based practitioner in

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specifically examining the impact of sensory processing andpraxis difficulties on educational performance across multi-ple educational environments.

Development and History of the SPM–SchoolThe SPM–School (which was called the School Assessmentof Sensory Integration, or SASI, until summer 2005) wasinitially created in 2000 following procedures set forth inthe occupational therapy literature (Benson & Clark, 1982;Bonder, 1989). A table of specifications was developed andvarious available sensory histories were reviewed to obtainan initial pool of items relevant to sensory integration the-ory that could be modified for use in the educational envi-ronment. This initial version of the test was sent to a panelof experts (n = 10), chosen from the School System andSensory Integration Special Interest Section committees ofAOTA, for their general review of face validity, the need forsuch a tool, and its practical usefulness. Another expertreview was completed using four experts in sensory integra-tion theory and test development, who completed item-by-item analysis of clarity, usefulness, freedom from bias, place-ment in categories and environments, and potentialspecificity and sensitivity. A third review was completed by40 school-based clinicians who each examined a subset of20 items (out of the tool’s 200+ items) and categorizedthem by sensory system, type of sensory processing dys-function, and appropriateness for each educational envi-ronment. Revisions occurred after each step based on thefeedback provided.

Two focus groups were held during these early phasesof development. In one focus group, school-based cliniciansand sensory integration experts freely generated observa-tions that they make in the schools that suggest to themthat a child may have issues with sensory processing andpraxis (i.e., rocking in chair, chewing on shirt). A secondfocus group, organized for participants who had used thetool, examined its format and provided comments and sug-gestions on the items, structure, overall content, and ease ofuse. After the focus groups, the tool was revised again.

Four case studies were completed with the early ver-sions of the tool. The first was with 4 students in an ele-mentary school in the midwestern United States. Two stu-dents were typically developing, and 2 were suspected tohave issues with sensory processing or praxis. Implementingthe tool allowed us to gather information about the ease oftool usage and the potential usefulness of the informationgathered for an actual educational team. The responses bythe occupational therapist and the team were positive; how-ever, this first use did lead to item changes in wording to

increase clarity for the educational personnel (Glennon,Henry, & Kuhaneck, 2003). Three additional case studies,all in an elementary school in the southwestern UnitedStates, were conducted to examine the SPM–School’s use-fulness and outcomes of completion. Interviews with theschool personnel involved in these case studies suggestedthat they found the tool useful, that they thought theSPM–School might be appropriate for pre-referral teamuse, and that the team valued the collaborative process thatoccurred with its use (Glennon, Henry, & Kuhaneck, 2005;Glennon, Henry, Kuhaneck, Parham, & Ecker, 2006).

Over a 2-year period, two pilot studies were conductedto examine the reliability and validity of SPM–School. Allpilot data were gathered by volunteer occupational therapycoordinators who distributed and gathered forms fromappropriate raters in each environment. To complete theforms, the raters reflected on the child’s performance over anentire month. The first pilot study, conducted between thefall of 2003 and spring of 2004 (Glennon, Henry, & Kuha-neck, 2004), completed an initial investigation of reliability.Participants included 23 children who were typically devel-oping, enrolled in kindergarten through sixth grade. Datawere analyzed via the SPSS statistical program to examineinternal consistency for all items in all environments. Inter-nal consistency was examined via Cronbach’s alpha, whichmeasures how well items correlate with each other and thetotal score. Cronbach’s alpha scores range from 0 to 1, andscores of .90 or greater are considered to be high (Portney &Watkins, 2000). Cronbach’s alpha scores for the first pilotstudy ranged from .97 to .99 for each individual sensoryprocessing environment and from .93 to .99 for each envi-ronment’s social participation items.

Data for the second pilot study were collected betweenthe late spring of 2004 through December 2004 (Glennonet al., 2005) and included 26 children who were typicallydeveloping and 25 children who were receiving occupa-tional therapy in their schools. The latter students wereidentified by their occupational therapist as having sensoryprocessing difficulties via the Sensory Integration and PraxisTests (Ayres, 1989), the Sensory Profile (Dunn, 1999), orobservations of behaviors that clinicians associate with sen-sory processing deficits. The statistical procedures used inthe first pilot study also were used for the second pilot study,with the addition of discriminant analysis to examine thevalidity of the instrument. Cronbach’s alpha for sensory pro-cessing items for children with sensory issues in the secondpilot study ranged from .87 to .99, whereas the range was.70 to .99 for the children who were typically developing.Cronbach’s alpha for social participation ranged from .91 to.97 for children with sensory issues and from .98 to .99 forchildren who were typically developing. Discriminant anal-

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ysis also was conducted to examine the SPM–School’s abil-ity to accurately discriminate children with sensory issuesfrom those without. The SPM–School accurately discrimi-nated 82.4% of the cases, both children who were typicallydeveloping and children who had sensory issues. TheSPM–School correctly classified children who were typi-cally developing as typical 92.3% of the time and classifiedchildren with sensory issues as children having issues 72%of the time.

DiscussionChanges within the occupational therapy profession in gen-eral, and within school-based practice in particular, havecreated a need for assessments that allow occupational ther-apists to contribute their knowledge of the sensory integra-tive frame of reference in ways that are useful to an educa-tional team. We believe that the SPM–School will fill thatneed. The results of the pilot studies suggested that theSPM–School is an internally consistent (Portney &Watkins, 2000) and reliable tool. However, the results alsosuggested that the groupings of sensory processing itemshad lower internal consistency than the social participationitem groupings. Perhaps sensory processing is a constructthat is more difficult to measure consistently than is socialparticipation. This finding is not unexpected, based on sen-sory integration theory, which hypothesizes that an individ-ual’s sensory processing fluctuates within and across sensorysystems and environments. Although temperament litera-ture reports that social behavior may be a stable trait(Lemery, Goldsmith, Linnert, & Mrazek, 1999; Pedlow,Sanson, Prior, & Oberklaid, 1993), it also may be that thesensory processing items were more difficult for the raters torate consistently. This difficult nature deepens the chal-lenges for researchers and practitioners to accurately assesssensory processing in natural environments to guide occu-pational therapy services.

The face and content validity suggested by expertreviewers and clinicians was further demonstrated throughthe tool’s ability to discriminate between children with andwithout sensory issues. Although this information is pre-liminary, it suggests that the SPM–School is a valid assess-ment for examining sensory processing issues in the schoolenvironment. As with any instrument development, refine-ment and improvement is a continuing process. The find-ings related to the psychometric properties of the early ver-sions of the SPM–School are particularly encouraging.

School-based practitioners have many responsibilitiesrelated to the use of sensory integration theory within theeducational system. An advantage of the SPM–School willbe the ability to compare a student’s performance across and

between environments and also to consider the student’ssocial participation. This comparison will allow the genera-tion of hypotheses regarding the impact of sensory process-ing and praxis issues on the student’s performance. Occu-pational therapists report that the ability to determineunderlying reasons for a child’s behavior is an importantaspect of their successful performance in schools (Case-Smith, 1997). We believe, based on feedback from ratersand coordinators and through our case studies, that the useof the SPM–School will assist occupational therapists indetermining sensory-based facilitators of and barriers toperformance; engender team discussion and collaboration;promote team problem solving; and allow for team inter-vention planning, which includes developing creativestrategies to improve a child’s functional performance.

The SPM’s final version will include two forms, aschool form and a home form. The Sensory ProcessingMeasure–Home was formerly the Evaluation of SensoryProcessing (Parham & Ecker, 2000). Normative data havebeen collected for both forms of the Sensory ProcessingMeasure, and further analysis of the tool’s psychometricproperties is continuing using Rasch analysis. This projectis being coordinated by Western Psychological Services(WPS), the publisher of the Sensory Processing Measure.

ConclusionOccupational therapy evaluation approaches in schoolsshould promote team problem solving and collaborationand examine performance in natural environments. Newassessments are needed to allow occupational therapists toconsider the sensory aspects of the environment and thesensory processing abilities of the child that may affect edu-cational performance. Initial results suggest that theSPM–School demonstrates internal consistency and facevalidity and is able to accurately discriminate between chil-dren who are typically developing and children who haveissues with sensory processing. Case studies completed withthe tool suggested its usefulness in pre-referral planning,team problem solving, education of team personnel, andsupporting collaboration. Final research phases with WPSwill provide normative data on large samples, for bothschool and home versions, and we believe that the final toolwill promote team collaboration in schools and clinics for agreater understanding of the impact of sensory processingon function. ▲

AcknowledgmentsThe authors acknowledge the contribution of Amy McLeanWeber, OTR/L, in the original design and development of

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this tool. We also thank all of the experts, clinicians, admin-istrators, educators, and parents who have assisted in thisprocess to date. They are too many in number to namehere, but we are eternally grateful to all.

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Parham, L. D., & Ecker, C. (2000). Evaluation of Sensory Process-ing. Unpublished test, University of Southern California, LosAngeles.

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The American Journal of Occupational Therapy 175

Defines occupational therapy, describes the scope of practice, and explains its contributions in

enabling people to participate in their chosen occupations; designing environments to support

participation in occupations; improving the quality, enhancing consumer satisfaction, and reducing

the costs of health care and social services; preventing disability; promoting health and wellness;

and facilitating the development of children. Also defines program planning, evaluation, and inter-

vention occurring within the boundaries of acceptable practice and the decision making of occupa-

tional therapy professionals.

BK

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