Sharon Cermak, Ed.D., OTR/L, FAOTA

Professor

Room: CHP 133
Phone: (323) 442-2879
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Biography

Sharon Cermak received her Bachelor of Science degree in Occupational Therapy from The Ohio State University, her Master of Science degree in Occupational Therapy from Boston University, Graduate Program, and her doctoral degree in Special Education at Boston University. Dr. Cermak is renowned for her expertise in Dyspraxia/ Developmental Coordination Disorder, a long-standing interest of hers. She co-edited a leading text, "Developmental Coordination Disorders", and more recently served as a member of an NIH Task Force on Childhood Motor Disorders.

Research Interests

Dr. Cermak’s current research focuses on health promotion in children with disabilities, which is a critical area of national health concern for children. She is involved in two NIH-funded projects as part of an interdisciplinary team of researchers at the Eunice Kennedy Shriver Center in Massachusetts. Dr. Cermak is Principal Investigator of an NIH-funded R21 grant, Physical Activity, Fitness and Obesity in Children with Coordination Disorders, which is designed to examine the effect of children’s motor coordination on their participation in physical activity and the effects on fitness, risk for obesity, and self-efficacy. Another area of research is with children with autism. Dr. Cermak is Co-Investigator on an NIH-funded R21 grant, Diet, Activity and Obesity in Children with Autism. Another related area of Dr. Cermak’s research expertise is the sensory processing and developmental effects of deprivation in institutionalized and post-institutionalized children. Dr. Cermak has been involved intensively in orphanages in Romania, conducting both research and service programs. She collaborates with Dr. Laurie Miller, M.D., Director of the International Adoption Clinic at Tufts New England Medical Center. Dr. Cermak was consultant and contributing author on a grant that Dr. Miller (PI) received from the Fogarty International Center for research on brain disorders in developing countries. The investigators on this study examined neurodevelopmental outcomes in children in Russian orphanages, and explored the contributions of the environment in promoting optimal brain development in young children.

Education

Doctor of Education (EDD) in Special Education
Boston University
1981

Master of Science (MS) in Occupational Therapy
Boston University
1972

Bachelor of Science (BS) in Occupational Therapy
The Ohio State University
1969

Publications

Books

Mauro, T., & Cermak, S. A. (2006). The everything parent's guide to sensory integration disorder. Avon, MA: Adams Media.

Cermak, S. A., & Larkin, D. (Eds.) (2002). Developmental coordination disorder. Albany, NY: Delmar/Thompson Learning. Abstract →← Abstract

A sweeping multidisciplinary, multicultural view of developmental coordination disorder (DCD), this work presents current advances from such fields as medicine, occupational therapy, physical therapy, pediatric neurology, human movement, and psychology. Description and assessment are fully covered, along with underlying mechanisms, functional implications, and intervention strategies. Special attention is given to hand skills and handwriting, physical fitness, social skills, and family issues.

Book Chapters

Cermak, S. A. (2011). Twenty five years of research in developmental dyspraxia. In A. J. Ayers (Ed.), Ayres dyspraxia monograph (25th anniversary edition). Torrance, CA: Pediatric Therapy Network.

Cermak, S. A. (2010). Position statement on terminology related to sensory integration dysfunction. In K. Morris (Ed.), Insights into sensory issues for professionals. Arlington, TX: Sensory World.

Daunhauer, L., & Cermak, S. A. (2008). Play occupations and the experience of deprivation. In D. Parham & L. Fazio (Eds.), Play in occupational therapy for children, 2nd ed. St. Louis, MO: Mosby Elsevier.

Cermak, S. A., & Osborne, P. (2006). Occupational therapy. In A. Crocker & M. Rubin (Eds.), Medical care for children and adults with developmental disabilities. Baltimore, MD: Brookes Publishing.

Cermak, S. A., & Mitchell, T. (2006). Sensory integration. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children. Baltimore, MD: Brookes Publishing.

Cermak, S. A. (2005). Perceptual functions of the hand. In A. Henderson & C. Pehoski (Eds.), Hand function in the child: Foundations for remediation (2nd ed.). Rockville, MD: American Occupational Therapy Association.

Journal Articles

Stein, L., Polido, J., Mailloux, Z., Coleman, G., & Cermak, S. A. (2011). Oral care and sensory sensitivities in children with Autism Spectrum Disorders. Special Care in Dentistry, 31(3), 102-110. Abstract →← Abstract

Children with autism spectrum disorders (ASD) are at high risk for oral disease. The aim of this study was to examine the contribution of sensory processing problems to challenges in receiving oral care for children with ASD. A questionnaire was sent to the parents of 206 children with disabilities to test the hypotheses that children with ASD, relative to children with other disabilities, experience greater difficulty with home-based and professional oral care, and that these difficulties may relate in part to sensory processing problems. The results partially supported these hypotheses. Compared to children with other disabilities, those with ASD had greater behavioral difficulties and sensory sensitivities that parents believed interfered with their child's oral care. Among children with ASD, sensory sensitivities were associated with oral care difficulties in the home and dental office, and with behavioral difficulties in the dental office. Utilizing strategies to modify the sensory environment may help facilitate oral care in children with ASD.

Mailloux, Z., Mulligan, S., Roley, S., Blanche, E. J., Cermak, S. A., Coleman, G., Bodison, S., & Lane, C. (2011). Verification and clarification of patterns of sensory integrative dysfunction. American Journal of Occupational Therapy, 65(2), 143-151. Abstract →← Abstract

Building on established relationships between the constructs of sensory integration in typical and special needs populations, in this retrospective study we examined patterns of sensory integrative dysfunction in 273 children ages 4–9 who had received occupational therapy evaluations in two private practice settings. Test results on the Sensory Integration and Praxis Tests, portions of the Sensory Processing Measure representing tactile overresponsiveness, and parent report of attention and activity level were included in the analyses. Exploratory factor analysis identified patterns similar to those found in early studies by Ayres (1965, 1966a, 1966b, 1969, 1972b, 1977, & 1989), namely Visuodyspraxia and Somatodyspraxia, Vestibular and Proprioceptive Bilateral Integration and Sequencing, Tactile and Visual Discrimination, and Tactile Defensiveness and Attention. Findings reinforce associations between constructs of sensory integration and assist with understanding sensory integration disorders that may affect childhood occupation. Limitations include the potential for subjective interpretation in factor analysis and inability to adjust measures available in charts in a retrospective research.

Tseng, M., Fu, C., Cermak, S. A., Lu, L., & Shieh, J. (2011). Emotional and behavioral problems in preschool children with autism: Relationship to sensory processing dysfunction. Research in Autism Spectrum Disorders, 5(4), 1441-1450. Abstract →← Abstract

This study aimed to investigate the sensory processing (SP) dysfunction and emotional and behavioral problems in preschool children with autism and then examine the relationship between the SP dysfunction and emotional and behavioral problems. The parents of 112 children aged 48–84 months (67 with autism; 45 age-matched typically developing) completed a demographic questionnaire, the Child Behavior Checklist-Chinese version (CBCL-C), and the Sensory Profile-Chinese version (SP-C). We found that 95.8% of children with autism who showed significant internalizing problems had at least one SP quadrant in the definite difference range, while 81.8% with significant externalizing problems had at least one SP quadrant in the definite difference range. Typically developing children showed lower percentages of 66.7% and 40.0%. Stepwise linear regression analysis revealed that in children with autism, avoiding and male gender were significant predictors of internalizing problems and sensitivity was a significant predictor of externalizing problems. In contrast, in typically developing children, avoiding was a significant predictor of internalizing problems and seeking was a significant predictor of externalizing problems. This study provided further understanding of the factors influencing emotional and behavioral problems in autism.

Stein, L., Foran, A., & Cermak, S. A. (2011). Occupational patterns of parents of children with Autism Spectrum Disorders: Revisiting Matuska and Christiansen’s Model of Lifestyle Balance. Journal of Occupational Science, 18(2), 115-130. Abstract →← Abstract

Parenting a child with autism spectrum disorder (ASD) is a unique and challenging experience. In this article we synthesized selected literature from psychology, neuroscience, occupational therapy, nursing, and other fields and utilized Matuska and Christiansen’s Model of Lifestyle Balance to organize the literature to present a theoretically grounded and occupation-based picture of the life experiences of parents of children with ASD. In doing so, we discerned a complex relationship among the five dimensions suggested by Matuska and Christiansen, prompting a refinement of their model to address this complexity. Overall, a variety of factors associated with caring for children with ASD have the potential to cause or contribute to negative psychological consequences such as stress, anxiety, and depression, as well as functional limitations and other health problems such as hypertension or diabetes. In order to promote health and general well-being, lifestyle changes to enhance balance may be necessary for many parents of children with ASD.

Cermak, S. A. (2010). Play and cognition among young children reared in an institution. Physical and Occupational Therapy in Pediatrics, 30(2), 83-97. Abstract →← Abstract

The relationship between cognitive functioning and play behaviors of children residing in an orphanage was examined. Twenty-six young children (15 boys) between 10 and 38 months of age participated. More developmentally competent play behaviors were highly related to better performance on cognitive functioning as measured by the Bayley Scales of Infant Development (r = .78, p < or = .01). The participants' play behaviors were less competent compared to previous data for children of the same chronological age living at home on four out of five levels of symbolic play (p < or = .05). However, when compared to data for children living at home with similar cognitive development, the participants demonstrated no significant differences in symbolic play (p > or =.05). The findings suggest that the relationship between thinking and playing is robust, even in an institutional environment. Additionally, practitioners assessing children from institutions who cannot engage in standardized testing may consider observing play behaviors to make an initial estimate of developmental status.

Bandini, L., Anderson, S., Curtin, C., Cermak, S. A., Evans, E., Scampini, R., Maslin, M., & Must, A. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. The Journal of Pediatrics, 157(2), 259-264. Abstract →← Abstract

OBJECTIVES: To define food selectivity and compare indices of food selectivity among children with autism spectrum disorders (ASDs) and typically developing children, and to assess the impact of food selectivity on nutrient adequacy. STUDY DESIGN: Food selectivity was operationalized to include food refusal, limited food repertoire, and high-frequency single food intake using a modified food frequency questionnaire and a 3-day food record. Food selectivity was compared between 53 children with ASDs and 58 typically developing children age 3-11 years. Nutrient adequacy was assessed relative to the dietary reference intakes. RESULTS: The children with ASDs exhibited more food refusal than typically developing children (41.7% of foods offered vs 18.9% of foods offered; P <.0001). They also had a more limited food repertoire (19.0 foods vs 22.5 foods; P <.001). Only 4 children with ASDs and 1 typically developing child demonstrated high-frequency single food intake. Children with a more limited food repertoire had inadequate intake of a greater number of nutrients. CONCLUSIONS: Our findings suggest that food selectivity is more common in children with ASDs than in typically developing children, and that a limited food repertoire may be associated with nutrient inadequacies.

Cermak, S. A., Curtin, C., & Bandini, L. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238-246. Abstract →← Abstract

Autism spectrum disorders comprise a complex set of related developmental disorders that are characterized by impairments in communication, social interaction, and repetitive behaviors. Impairments in sensory processing are also extremely common. The prevalence of autism spectrum disorders is increasing and is currently estimated to affect 1 in 150 children. Autism spectrum disorders are considered to be a major health and educational problem, affecting many areas of daily living, including eating. Children with autism spectrum disorders are often described as picky or selective eaters. This article provides a comprehensive narrative review of the empirical literature over the last 25 years on food selectivity and nutritional adequacy in children with autism spectrum disorders. The possible contributions of sensory factors, such as sensory sensitivity, to food selectivity are discussed. The need for an interdisciplinary approach to managing atypical eating patterns in children with autism spectrum disorders is highlighted.

Ben-Sasson, A., Hen, L., Fluss, R., Cermak, S. A., Engel-Yeger, B., & Gal, E. (2009). A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(1), 1-11. Abstract →← Abstract

Sensory modulation symptoms are common in persons with autism spectrum disorders (ASD); however have a heterogeneous presentation. Results from 14 studies indicated a significant high difference between ASD and typical groups in the presence/frequency of sensory symptoms, with the greatest difference in under-responsivity, followed by over-responsivity and sensation seeking. Three moderators that reduced the variability in findings among studies were: chronological age, severity of autism, and type of control group. Sensory differences were highest for studies of children ages 6-9 years, samples with more than 80% with an autism diagnosis, and compared to a CA matched versus a MA or DD matched group. It is important to consider these moderators in the design of studies and interventions addressing sensory symptoms.

Chen, Y., Tseng, M., Hu, F., & Cermak, S. A. (2009). Psychological adjustment and attention in children with developmental coordination disorder using different motor tests. Research in Developmental Disabilities, 30(6), 1367-77. Abstract →← Abstract

This study examined the consistency between the findings of developmental coordination disorder (DCD) as identified by the Bruininks–Oseretsky Test of Motor Proficiency (BOTMP) and the Movement Assessment Battery for Children (MABC), and explored the psychosocial and attention characteristics of children with DCD identified by the two motor tests, respectively. Participants were 270 children (male: 161, female: 109; age 7.74 ± 0.81 years). The association between DCD status identified by each of the motor tests and psychosocial problems measured by the Child Behavioral Checklist-Chinese version (CBCL-C) was examined using multiple logistic regressions. The results showed that DCD identified by the BOTMP was associated with high scores on the Withdrawn and Social Problems, with a higher proportion of females identified. DCD identified by the MABC was associated with high scores on the Withdrawn and Attention Problems and low score on the Aggressive Behavior. The results reaffirmed the lack of consistency between the motor tests and indicated that children identified by the two motor tests showed different profiles of attention and psychosocial adjustment.

Cermak, S. A. (2009). Deprivation and sensory processing in institutionalized and post-institutionalized children, Part I. Sensory Integration Special Interest Section Quarterly, 32(2), 1-3.

Ben-Sasson, A., Simmell, K., & Cermak, S. A. (2009). Sequence of gestural representation in children with high functioning autism. Israeli Journal of Occupational Therapy, 8(4), E57-E73. Abstract →← Abstract

There is controversy as to whether gestural representation deficits in autism spectrum disorders reflect a language or/and a motor-based deficit. In this study children with high functioning autism (HFA, n=26), children with language impairment (LI, n=24), and typically developing children (n=30) demonstrated and described tooth brushing. Children with HFA showed a significantly lower level of gestural representation compared to the typical group but did not differ from LI group, and demonstrated significantly fewer recognizable actions within tooth brushing than both comparison groups but did not differ in the number of steps they described. The lower gestural representation level in both clinical groups may reflect a symbolic representation impairment, while the specific difficulties of children with HFA in presenting an elaborate and accurate sequence of motor actions may more closely reflect dyspraxia. The planning and initiation of motor actions allow us to communicate our needs, feelings, and thoughts through gestures. Specifically, gestural representation enables us to remember skill steps for future use and enact them. Gestural representation refers to the ability to demonstrate a familiar action of tool use in absence of the object of the action, otherwise called pantomime (Green et al., 2002; Hill, Bishop, & Nimmo-Smith, 1998). Children with autism spectrum disorders (ASDs) often show difficulties in producing meaningful gestures compared to typically developing children (Green et al.; Smith & Bryson, 2007), particularly in demonstrating gestures of object-use

Cermak, S. A. (2009). Deprivation and sensory processing in institutionalized and post-institutionalized children, Part II. Sensory Integration Special Interest Section Quarterly, 32(3), 1-4.

Chen, Y., Tseng, M., Hu, F., & Cermak, S. A. (2009). Psychosocial adjustment and attention in children with developmental coordination disorder using different motor tests. Research in Developmental Disabilities, 30(6), 1367-1377. Abstract →← Abstract

Toglia, J., & Cermak, S. A. (2009). Dynamic assessment and prediction of learning potential in clients with unilateral neglect. American Journal of Occupational Therapy, 63(5), 569-79. Abstract →← Abstract

We investigated the application of dynamic assessment in examining learning potential for adults with right hemisphere stroke and unilateral neglect. Forty adults with right cerebrovascular accident were randomly assigned to a control or dynamic group. Both groups were administered standard pretests and posttests of unilateral neglect. The dynamic group received cues, strategy training, and feedback during an object search task. Multivariate analysis of covariance indicated significant differences between groups on the object search task, with reduced unilateral neglect in the dynamic group. Greater initiation of left-sided search, strategy use, and near and intermediate transfer of learning were observed in the dynamic group. The brief dynamic assessment, developed for this study, provided an opportunity to observe the client's ability to incorporate strategy training and feedback across visual search tasks. This assessment approach has the potential to characterize learning profiles and to guide intervention decisions.

Ben-Sasson, A., Cermak, S. A., Orsmond, G., Tager-Flusberg, H., Kadlec, M., & Carter, A. (2008). Sensory clusters of toddlers with autism spectrum disorders: Differences in affective symptoms. Journal of Child Psychology and Psychiatry, 49(8), 817-825. Abstract →← Abstract

Individuals with autism spectrum disorders (ASDs) show variability in their sensory behaviors. In this study we identified clusters of toddlers with ASDs who shared sensory profiles and examined differences in affective symptoms across these clusters. Using cluster analysis 170 toddlers with ASDs were grouped based on parent rating of the Infant Toddler Sensory Profile under-responsivity, over-responsivity, and seeking scales. Affective symptoms were evaluated with the Infant Toddler Social Emotional Assessment. Three clusters were identified: (1) low frequency of sensory symptoms (n = 44); (2) high frequency of symptoms (n = 49); and (3) mixed (n = 77); high frequency of under-and over-responsivity and low frequency of seeking). Relative to the low frequency cluster, parents rated toddlers in the high frequency and mixed clusters (both characterized by high frequencies of sensory under- and over-responsivity) as higher on negative emotionality, depression, and anxiety symptoms. Sensory and affective differences among clusters remained after co-varying severity of ASD symptoms. Interdisciplinary assessments are recommended for toddlers with ASDs in order to identify the interplay of sensory and affective symptoms.

Tirella, L., Chan, W., Cermak, S. A., Litvinova, A., Salas, K., & Miller, L. (2008). Time use in Russian Baby Homes. Child: Care, Health, and Development, 34(1), 77-86. Abstract →← Abstract

We investigated time use of Russian children residing in Baby Homes to document their opportunities and experiences during institutional care. Time use of 138 non-special needs, randomly selected children (65 female vs. 73 male, age 1 month to 4 years) in Baby Homes in Murmansk, Russia, was analysed. Baby Home specialists were trained in time-use spot observation methodology. Each child was observed every 10 min for 5 h (31 observations/child; >4000 data points). At each observation, we coded: who the child was with, adult role, what the child was doing, location and vocalizations. Children spent 50% of their time alone, 27% with a caregiver, 15% with another adult, and 7% with another child. Infants spent significantly more time alone (65%) than toddlers (43%) or pre-schoolers (46%) [F(2,133) = 13.05, P < 0.0001]. Caregivers supervised children (58%), led group activities (16%), cared for individuals (14%), or were absent from the room (12%). Children spent the most time (32%) in activities of daily living; remaining time was spent in meaningful play (27%), non-purposeful activity (16%) or sleep (18%). The percentage of time spent in meaningful play significantly increased across age groups [infants 10%, toddlers 25%, pre-schoolers 36%, F(2,133) = 26.9, P < 0.001]. Infants (23%) and toddlers (20%) spent significantly more time than the older group (10%) in non-purposeful activity [F(2,133) = 26.9, P < 0.001]. In 12% of observations, an adult was speaking to the child, in 10% to the group, and <1% to another adult. Child vocalizations varied by age: infants 42% of observations, toddlers 56%, and pre-schoolers 59%. Older children directed more vocalizations to adults than younger children [F(2,133) = 24.47, P < 0.001]. Time use of children residing in Baby Homes is limited by routinized schedules and care, at the expense of child-directed or interactive play with adults. Despite close proximity and living in group care, children's vocalizations and interactions with others are limited.

Daunhauer, L., Coster, W., Tickle-Degnen, L., & Cermak, S. A. (2007). Effects of caregiver-child interactions on play occupations among young children institutionalized in Eastern Europe. American Journal of Occupational Therapy, 61, 429-440. Abstract →← Abstract

We investigated whether children institutionalized in an orphanage would engage in more developmentally competent play with their caregivers as opposed to playing alone and whether specific qualities of caregiver-child interactions were associated with more developmentally competent play. Twenty-six children, ages 10 to 38 months, participated in independent play sessions and in a play session with a caregiver. Twelve pediatric experts rated both child and caregiver behaviors for the interactive sessions. The children demonstrated more developmentally competent play when interacting with a caregiver than when playing alone. Longer periods of institutionalization were associated with less improvement in play performance from independent to interactive play sessions. Successful engagement for the child was associatedm with having a caregiver who provided more structure and assistance and who was directive and encouraging. Caregivers facilitated more developmentally competent participation in play with children residing in an orphanage, despite the fact that these interactions occurred in an environment vulnerable to many challenges not typical of an exclusive caregiver-child relationship.

Miller, L., Chan, W., Litvinova, A., Rubin, A., Tirella, L., & Cermak, S. A. (2007). Medical diagnoses and growth of children residing in Russian orphanages. Acta Paediatrica, 96(12), 1765-9. Abstract →← Abstract

AIMS: Survey the health of young children residing in Russian orphanages. METHODS: Retrospective chart review of all 193 'healthy' young children (105M:88F, age range 2-72 months) residing in orphanages in Murmansk, Russia. RESULTS: Mothers of these institutionalized children had complex histories including chronic health problems (38%), use of tobacco (41%), alcohol (39%) and illicit drugs (7%). Frequent diagnoses of the children included rickets (21%), foetal alcohol syndrome (10%), anemia (6%), developmental delay (11% mild, 25% moderate, 28% severe), behavioural problems (60%) and 'perinatal encephalopathy' (46%<1 year of age). At orphanage entry, growth delays were common (underweight 34%, short stature 25%, microcephaly 34%). During orphanage residence, height z scores further decreased (p=0.01), but head circumference improved (p<0.0001, paired t-tests). Head circumferences increased significantly in 62% of microcephalic children. Smaller children (z score<-2) at entry exhibited more rapid growth (z score/month) for weight (+0.24 vs. -0.12, p=0.04), height (+0.81 vs. -0.65, p=0.0001), and head circumference (+1.02 vs. -0.10, p=0.0004). Growth correlated with child developmental status. CONCLUSIONS: Young institutionalized children in Murmansk have complex medical status, social histories and frequent growth and developmental delays. Anthropometric measurements-particularly head circumference-improved during orphanage residence in children who entered with more severe growth delays.

May-Benson, T., & Cermak, S. A. (2007). Development of an assessment of ideational praxis. American Journal of Occupational Therapy, 61(2), 148-153. Abstract →← Abstract

This study developed an assessment of ideational praxis, examined its psychometric properties, and analyzed age and gender trends in children who were typically developing. Part 1 developed items and scoring criteria of the Test of Ideational Praxis (TIP) and examined interrater reliability and internal consistency. Part 2 studied performance of 80 typically developing children between ages 5 and 8 years. The TIP demonstrated acceptable interrater reliability (ICC = .85) and internal consistency (coefficient alpha = .74). Children who were typically developing demonstrated age and gender trends. Girls scored higher than boys, and older children scored higher than younger children. The TIP is the first objective assessment for identification of ideational abilities and is a reliable assessment tool. Further research is needed to validate the construct of ideation and examine the TIP’s ability to discriminate between children with and without ideational difficulties.

Ben-Sasson, A., Cermak, S. A., Orsmond, G., Carter, A., & Fogg, L. (2007). Can we differentiate sensory over-responsivity from anxiety in toddlers? Perspectives of occupational therapists and psychologists. Infant Mental Health Journal, 28(5), 536-558. Abstract →← Abstract

Suppose a toddler becomes distressed after hearing a loud noise or when getting messy; are these indicators of sensory over-responsiveness or indicators of anxiety? There is little evidence regarding the distinction between sensory over-responsivity and anxiety disorders in toddlers. This construct validity study examined differences between occupational therapists' and psychologists' judgments of behaviors as representing sensory processing disorders (SPD) versus anxiety disorders. Twenty-four occupational therapists and 25 psychologists completed a mailed survey, rating items from sensory and anxiety scales as representing sensory and/or anxiety disorders in toddlers, and analyzing cases of toddlers with these disorders. Occupational therapists were more likely to rate items as representing SPD than psychologists, and occupational therapists were more certain of the distinction of the sensory scales from anxiety. For the case designed to present a general anxiety disorder and the one designed to present sensory over-responsivity, more occupational therapists diagnosed as sensory over-responsive, while more psychologists diagnosed with a general anxiety disorder. The overlap in judgments of sensory over-responsivity and anxiety supports the notion that these constructs in part reflect different professionals' perspectives upon behaviors as well as the difficulty in distinguishing these constructs in toddlers.

Miller, L., Anzalone, M., Lane, S., Cermak, S. A., & Osten, E. (2007). From the guest editor - Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy, 61(2), 135-140. Abstract →← Abstract

Sensory integration is a long-standing and growing area of practice in occupational therapy. Debate and discussion with colleagues have led us to develop a proposed taxonomy reflecting a new classification scheme to enhance diagnostic specificity. The nosology proposed here is rooted in empirical data first published by Ayres that has evolved based on empirical and theoretical information. This new nosology provides a viewpoint for discussion and research.

Ben-Sasson, A., Cermak, S. A., Orsmond, G., Tager-Flusberg, H., Carter, A., Kadlec, M., & Dunn, W. (2007). Extreme sensory processing behaviors in toddlers with autism spectrum disorders. American Journal of Occupational Therapy, 61(5), 584-592. Abstract →← Abstract

This study examined the incidence of extreme sensory modulation behaviors in toddlers with autism spectrum disorders (ASD) and investigated the consistency of sensory information across measures. Parent report of sensory behaviors in 101 toddlers with ASD was compared with 100 toddlers who were typically developing matched on chronological age and 99 additional infants or toddlers matched on mental age. Measures included the Infant/Toddler Sensory Profile, Infant-Toddler Social Emotional Assessment, Autism Diagnostic Interview-Revised, and Autism Diagnostic Observation Schedule-Generic. Toddlers with ASD were most distinct from typically developing groups in their high frequency of underresponsiveness and avoiding behaviors and their low frequency of seeking. Within the toddlers with ASD, there were significant associations across sensory parent report measures, but parent report was not correlated with clinical observation. Findings point to the early onset of an extreme sensory profile in ASD. Occupational therapists need to assess multiple domains of sensory behaviors to accurately identify the needs of toddlers with ASD.

Miller, L., Chan, W., Litvinova, A., Rubin, A., Comfort, K., Tirella, L., Cermak, S. A., Morse, B., & Kovalev Boston-Murmansk Orphanage Research Team, I. (2006). Fetal alcohol spectrum disorders in children residing in Russian orphanages: A phenotypic study. Alcoholism: Clinical and Experimental Research, 30(3), 531-538. Abstract →← Abstract

Alcohol use in Russia is among the highest in the world. Over 600,000 children reside in institutional care in Russia, most of them in baby homes and orphanages. The actual prevalence of fetal alcohol spectrum disorders (FASD) among these children is unknown. Therefore, we performed a systematic survey of phenotypic features associated with prenatal alcohol exposure among institutionalized Russian children and related these findings to their growth, development, medical, and social histories. Phenotypic screening was conducted of all 234 baby home residents in the Murmansk region of Russia (mean age 21+12.6 months). Phenotypic expression scores were devised based on facial dysmorphology and other readily observable physical findings. Growth measurements from birth, time of placement in the baby home, and at present were analyzed. In addition, the charts of 64% of the children were randomly selected for retrospective review. Information collected included maternal, medical, developmental, and social histories. Thirteen percent of children had facial phenotype scores highly compatible with prenatal alcohol exposure and 45% had intermediate facial phenotype scores. These scores correlated with maternal gravidity and age. At least 40% of mothers in whom history was available ingested alcohol during pregnancy; some also used illicit drugs and tobacco. Z scores for growth measurements corresponded to phenotypic score, as did the degree of developmental delay. Children with no or mild delay had significantly lower phenotypic scores than those with moderate or severe delay (p=0.04); more than 70% of children with high phenotypic scores were moderately or severely delayed. More than half of residents of the baby homes in Murmansk, Russia, have intermediate (45%) or high (13%) phenotypic expression scores suggesting prenatal exposure to alcohol. Despite good physical care, stable daily routine, availability of well-trained specialists, and access to medical care, these vulnerable children show significant growth and developmental delays compared with their institutionalized peers.

Lin, S., Cermak, S. A., Coster, W., & Miller, L. (2005). The relation between length of institutionalization and sensory integration in children adopted from Eastern Europe. American Journal of Occupational Therapy, 59(2), 139-47. Abstract →← Abstract

To examine the relation between length of institutionalization and sensory integration in children adopted from Eastern Europe. The Sensory Integration and Praxis Tests (SIPT) and the Developmental and Sensory Processing Questionnaire were administered to 60 adopted children, 4 years to 8 years, 11 months of age. Thirty had longer institutionalization histories (mean: 34 months; LIH group) and the other 30 had shorter institutionalization histories (mean: 3 months; SIH group). The LIH group demonstrated significantly lower scores than the SIH group on the SIPT in vestibular-proprioceptive, visual, and praxis areas, and effect sizes ranged from .09 to 1.13. The LIH group also had significantly more frequent behaviors suggestive of sensory modulation dysfunction compared to the SIH group, particularly in touch and movement seeking, vision, and audition. Effect sizes ranged from 0 to 1.39. Longer lengths of institutionalization are associated with more atypical sensory discrimination, praxis, and sensory modulation scores in children adopted from Eastern European orphanages. The areas of sensory integration that appear to be more vulnerable to deprived conditions in early childhood are vestibular-proprioceptive, tactile, visual, auditory, and praxis. Adopted children with lengthy periods of institutionalization may benefit from occupational therapy for early sensory integrative and developmental screenings.

Marr, D., & Cermak, S. A. (2003). Consistency of handwriting in early elementary students. American Journal of Occupational Therapy, 57(2), 161-7. Abstract →← Abstract

The purpose of this longitudinal study was to examine the consistency of handwriting in children from the beginning of kindergarten to the middle of the first-grade year. Consistency was defined as retaining the same qualitative performance and relative ranking over time. Ninety-three children were tested at the beginning of the kindergarten year and again in the middle of the first-grade year on the Scale of Children's Readiness In PrinTing (SCRIPT). Data were analyzed with a repeated measures analysis of variance (ANOVA) (3 performance groups [lower, middle, upper] x 2 grades) followed by a Tukey's HSD post hoc analysis. An analysis of the change in performance of individual children also was conducted. The main effects and the interaction in the ANOVA were significant. Post hoc analysis for grade demonstrated that both the middle and the lower performing groups showed a significant improvement from kindergarten to first grade, whereas the upper performing group remained unchanged. Post hoc analysis found significant differences among all three performance groups in kindergarten. In first grade, the lower performing group continued to score significantly lower than the middle and upper performing groups, whereas the middle and upper performing groups were not significantly different. Analysis of individual data revealed that 60% of the students were consistent in their performance from kindergarten to first grade. The correlation between kindergarten SCRIPT scores and first-grade SCRIPT scores provides initial evidence that a moderately consistent pattern of handwriting performance exists. Students with low- and middle-ranked handwriting skills show relatively similar improvement over time, whereas change for students ranked high is limited.

Cermak, S. A., Marr, D., Cohn, E., & Henderson, A. (2003). Fine motor activities in Head Start and kindergarten classrooms. American Journal of Occupational Therapy, 57(5), 550-7. Abstract →← Abstract

The purpose of this study was to describe and compare the fine motor activities in Head Start and kindergarten classrooms in order to open a dialogue between the two contexts about the fine motor activities children in preschool will face in kindergarten. Children in 10 Head Start and 10 kindergarten classrooms were observed for 1 day each. Time spent in activities was categorized into four groups: fine motor activities with no academic purpose, fine motor activities with academic purpose, academic activities with no fine motor component, and nonacademic activities with no fine motor component. Percentages of time were calculated and t tests were used for comparison between contexts. Children in Head Start spent 27%-46% (mean of 37%) of the in-class day in all fine motor activities whereas children in kindergarten spent 36%-66% (mean of 46%). For children in kindergarten, 42% of total fine motor activity time involved paper and pencil activities. In contrast, children in Head Start spent 10% of total fine motor activity time in paper and pencil activities. The higher mean percent of time spent in fine motor activities in kindergarten classrooms suggests a developmentally appropriate increase in fine motor demands. The percent of paper and pencil activity time the children engaged in substantially increased from Head Start to kindergarten. The findings describe a difference between the two environments, informing Head Start of the fine motor demands their graduates face in kindergarten.

Marr, D., & Cermak, S. A. (2002). Predicting handwriting performance of early elementary students with the developmental test of visual-motor integration. Perceptual & Motor Skills, 95(2), 661-9. Abstract →← Abstract

The purpose of this study was to examine use of the Developmental Test of Visual-Motor Integration in predicting handwriting performance of early elementary students and the contribution of sex. An additional purpose was to examine whether successful completion of the first nine figures or the oblique cross from the test predicted handwriting. 101 children were tested at the beginning of their kindergarten year and again in the middle of the first-grade year on the Scale of Children's Readiness In PrinTing (SCRIPT). The VMI kindergarten scores did not significantly predict first-grade SCRIPT scores for the sample as a whole. When boys and girls were considered separately. VMI scores predicted handwriting SCRIPT scores for girls, but accounted for only 10% of the variance. Successful performance on the first nine VMI figures was significantly associated with handwriting for girls but not boys, while the oblique cross did not significantly predict handwriting performance. These results do not provide clear support for administration of the Developmental Test of Visual-Motor Integration during kindergarten as a tool to identify children at risk for handwriting difficulties.

Cohn, E., & Cermak, S. A. (1998). Including the family perspective in sensory integration outcomes research. American Journal of Occupational Therapy, 52(7), 540-6. Abstract →← Abstract

Occupational therapy, along with other health and rehabilitation professions, is experiencing an increased emphasis on measurement of intervention outcomes. The results of outcomes research are being used to develop practice guidelines, set standards for reimbursement, and justify health care policy. The outcome assessments used by therapists reflect our belief systems and the assumptions about behaviors we expect to influence. Using a sensory integration perspective to illustrate key points, we present a conceptual framework that is based on the disablement framework and Coster's occupational functioning for children model. We highlight the need to examine each of the multiple levels at which intervention may influence child and family function and the links among levels. Sensory integration theory and efficacy studies are reviewed to identify assumptions relative to how sensory integration affects the everyday occupations of children in the context of their families. Potential research methods and assessments are suggested to include the family perspective in outcome studies.

Katz, N., Champagne, D., & Cermak, S. A. (1997). Comparison of the performance of younger and older adults on three versions of a puzzle reproduction task. American Journal of Occupational Therapy, 51(7), 562-568. Abstract →← Abstract

Because constructional ability is a crucial perceptual-motor skill that relates to daily functioning, it should be accurately assessed in clients with neurological dysfunction. This study examined three versions ofthe Puzzle Reproduction task (a constructional ability task) of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) in order to determine whether a reduced detail version of the task would be easier (i.e., require less time to complete) than the original version and whether a subplacement version would be more difficult to perform (i.e., require more time to complete) than the original version. In addition, the study examined whether older adult subjects would perform more slowly than younger adult subjects. Seventy-two right-handed adults with no disabilities were divided into two age groups: 18 to 30 years old (n = 36) and 58 to 70 years old (n = 36). Each subject was tested on one of three versions of the LOTCA Puzzle Reproduction task (i.e., original, subplacement, simplified). For the older subjects, the simplified version ofthe task required significantly less time than the original version, although there was not a significant time difference between the original and subplacement versions. For the younger subjects, the subplacement version required significantly more time than the original version, but there was no significant time difference between the original and simplified versions. Results also indicated that older subjects took significantly longer to perform all thr'ee versions of the task than did the younger subjects. The findings support the use of the simplified version of the LOTCA Puzzle Reproduction task with older adults or with persons with major cognitive-perceptual difficulties. Further studies of the level of difficulty of the subplacement version are needed to examine whether this version is more sensitive to constructional deficits in a sample of persons with neurological impairments because even mild constructional deficits have been shown to relate to disabilities in daily functioning.

Cermak, S. A., & Daunhauer, L. (1997). Sensory processing in the postinstitutionalized child. American Journal of Occupational Therapy, 51(7), 500-507. Abstract →← Abstract

The purpose of this study was to examine whether children adopted from Romanian orphanages have difficulty with sensory processing and related behaviors. Seventy-three children adopted from Romanian orphanages were compared with 72 peers who were typically developing. The subjects' ages ranged from 3 to 6 years. The parent-report Developmental and Sensory Processing Questionnaire was used to assess sensory processing and related behaviors. The tooL consists of questions in six sensory processing domains and five related behavioral domains. Multiple t tests indicated that the subjects adopted from Romanian orphanages demonstrated significantly greater problems than those in the control group on five of the six sensory processing domains: touch, movement-avoids, movement-seeks, vision, and audition. Additionally, the Romanian subjects exhibited significantly greater problems than the controL subjects on four of the five behavioral domains: activity level, feeding, organization, and social-emotional. These findings substantiate clinical observations and parent reports of sensory processing deficits in children adopted from Romanian orphanages and highlight the criticaL importance of the environment for sensory integration. The findings also enhance our understanding of how children who were previously institutionalized respond to the human and physical environment.

Rainville, E., Cermak, S. A., & Murray, E. (1996). Supervision and consultation services for pediatric occupational therapists. American Journal of Occupational Therapy, 50(9), 725-731. Abstract →← Abstract

Occupational therapists with advanced experience of expertise provide supervision and consultation services in a variety of settings. This pilot study examined the use of such supervision and consultation services by pediatric occupational therapists. Special education administrators and pediatric occupational therapists from Massachusetts, a state often regarded as a leader in special education, responded to surveys designed especially for this study. These surveys asked about current supervision and consultation use, satisfaction with present services, and the need for additional resources in this area. Opinions regarding practice areas that would best be addressed by supervision and consultation were also obtained. Both administrator and therapist respondents agreed that expert occupational therapy supervision and consultation are needed. Identified areas of interest were classroom supervision and consultation strategies, service delivery decisions, and evaluation methods. Pediatric occupational therapists need expert supervision and consultation from occupational therapists with advanced experience or expertise in addition to traditional management, education, and training methods.

York, C., & Cermak, S. A. (1995). Visual perception and praxis in adults after stroke. American Journal of Occupational Therapy, 49(6), 543-550. Abstract →← Abstract

The purpose of this study was to examine the performance of persons with right cerebrovascular accident (RCVA) and persons with left cerebrovascular accident (LCVA) on a variety of measures of praxis and visual perception in order to examine the relative contributions of the left and right cerebral hemispheres to praxis and perception. Forty-five subjects, 15 with RCVA, 15 with LCVA, and 15 without CVA (control subjects), were tested on three tests of praxis-praxic production, gesture comprehension, and gesture discrimination--and selected tests of visual perception, including the Judgment of Line Orientation Test, the Motor Free Visual Perception Test, the Hooper Visual Organization Test, and the Line Bisection Test. Subjects in both groups with CVA performed more poorly on all of the tests than did control subjects. The group with LCVA performed most poorly on tests of gesture comprehension and praxis production, whereas the group with RCVA performed most poorly on tests of gesture discrimination and visual perception. Conclusion These findings suggest that both the right and left cerebral hemispheres contribute to different aspects of praxis. Elements of visual perception may be related to gesture comprehension, gesture discrimination, and praxis production in adults who have had stroke. These findings have clinical implications regarding instructional style and perceptual and praxic training.

Cermak, S. A., Katz, N., McGuire, E., Greenbaum, S., Peralta, C., & Maser-Flanagan, V. (1995). Performance of Americans and Israelis with cerebrovascular accident on the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA). American Journal of Occupational Therapy, 49(6), 500-6. Abstract →← Abstract

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) measures the cognitive performance of persons with cerebrovascular accident (CVA). Alltough this assessment was developed and standardized in Israel, it is frequently used in the United States. The purpose of this study was to identify whether differences in performance on the LOTCA existed between Americans and Israelis who have had strokes. Additionally, this study was designed to compare the performance of persons with right CVA with the performance of persons with left CVA because the normative data for the L0TCA does not include separate information for these two groups. The LOTCA was administered to 25 Americans with CVA (19 right CVA and 6 left CVA) and 56 Israelies with CVA (26 right CVA and 30 left CVA). On the majority of LOTCA subtests, there were no significant differences between American and Israeli subjects. Only one subtest, Orientation to Time, revealed significant differences between Americans and Israeli subjects both for subjects with right CVA and subjects with left CVA. Examination of subjects with right CVA versus subjects with left CVA also indicated few differences. Only one subtest, Pegboard Construction, revealed significant differences between subjects with right CVA and subjects with left CVA for both American and Israeli subjects. The LOTCA is an appropriate tool for occupational therapists to use in assessing Americans who have had strokes. In addition, for the most part, the subtests of the LOTCA assess cognitive-perceptual abilities that are not specific to the right or left cerebral hemisphere.

Tseng, M., & Cermak, S. A. (1993). The influence of ergonomic factors and perceptual-motor abilities on handwriting performance. American Journal of Occupational Therapy, 47(10), 919-926. Abstract →← Abstract

Difficulty with handwriting is one of the most frequent reasons that children in the public schools are referred to occupational therapy. Current research on the influence of ergonomic factors, such as pencil grip and pressure, and perceptual-motor factors traditionally believed to affect handwriting, is reviewed. Factors such as visual perception show little relationship to handwriting, whereas tactile-kinesthetic, visual-motor, and motor planning appear to be more closely related to handwriting. By better understanding the ergonomic and perceptual-motor factors that contribute to and influence handwriting, therapists will be better able to design rationally based intervention programs.

McHale-Med, K., & Cermak, S. A. (1992). Fine motor activities in elementary school: Preliminary findings and provisional implications for children with fine motor problems. American Journal of Occupational Therapy, 46(10), 898-903. Abstract →← Abstract

This study was designed to obtain a detailed picture of the fine motor requirements in regular elementary school classrooms. This knowledge is critical for occupational therapists in working with children with fine motor and handwriting problems who are mainstreamed into regular classes. The allocation of time to fine motor activities and the types of fine motor tasks children are expected to perform in elementary school were investigated through the observation of six elementary school classrooms. A written minute-by-minute record of one whole day's activities in each classroom showed that 30% to 60% of the day was allocated to fine motor activities, with writing tasks predominating over other manipulative tasks. Implications for children with fine motor difficulties include the need for modifications to volume of work, types of tasks, and materials.

Henderson, A., Cermak, S. A., Coster, W., Murray, E., Trombly, C., & Tickle-Degnen, L. (1991). The issue is- Occupational science is multidimensional. American Journal of Occupational Therapy, 45(4), 370-2. Abstract →← Abstract

The development of a science of occupation is one of the goals of the profession of occupational therapy. Disagreement exists, however, as to the definition of occupational science and therefore as to what is considered legitimate occupational therapy research. An overly restrictive interpretation of the term occupational science will affect the funding and publication of research studies, resulting in potentially valuable knowledge being lost to the profession.

Cermak, S. A., & Murray, E. (1991). The validity of the constructional subtests of the Sensory Integration and Praxis Tests. American Journal of Occupational Therapy, 45(6), 539-543. Abstract →← Abstract

This study was designed to examine the validity of the Design Copying and Constructional Praxis subtests of the Sensory Integration and Praxis Tests (SIPT) (Ayres, 1989) through an examination of convergent validity and the use of contrast groups. The subjects were 39 children aged 5 to 8 years. Of these children, 21 had learning disabilities and 18, who served as the control group, had no learning disabilities. The subjects were administered the SIPT as well as four other standardized measures of constructional abilities: the Developmental Test of Visual-Motor Integration (Beery, 1980), the Block Design subtest of the Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974), the Primary Visual Motor Test (Haworth, 1970), and the Rey-Osterrieth Complex Figure Test (Waber & Holmes, 1985). The results indicated that the children with learning disabilities performed significantly more poorly than did the control subjects on both the Design Copying and Constructional Praxis subtests. These two subtests showed moderately high correlations (.46 to .71) with the other tests of constructional abilities when both groups were combined. Correlations were mostly in the moderate range for the children with learning disabilities but were generally not significant for the control sample. The results are discussed in terms of task demands and subject variability.

Cermak, S. A., Morris, M., & Koomar, J. (1990). Praxis on verbal command and imitation. American Journal of Occupational Therapy, 44(7), 641-5. Abstract →← Abstract

Nondysfunctional 4-year-old and 6-year-old children were administered the Praxis on Verbal Command subtest of the Sensory Integration and Praxis Tests (SIPT) (Ayres, 1989) under two conditions. One condition was administered in the standardized manner on verbal command; the other involved administration of the same items on imitation. An analysis of variance indicated that the variables of age and condition were significant, whereas sex was not significant. The Age x Condition interaction was also significant. Scheffe multiple comparisons revealed a significant difference between 4-year-olds and 6-year-olds on verbal command but not on imitation. Verbal-command scores were significantly lower than imitation scores for the 4-year-olds but not for the 6-year-olds.

Witt, A., Cermak, S. A., & Coster, W. (1990). Body part identification in 1- to 2-year-old children. American Journal of Occupational Therapy, 44(2), 147-153. Abstract →← Abstract

The purpose of this study was to examine the developmental sequence of body part identification in very young children, 11 to 25 months of age. In the first part of the study, 113 children, divided into five age groups (12-month-olds, 15-month-olds, 18-month-olds, 21-month-olds, and 24-month-olds), were asked to point to 20 body parts on a doll. The results indicated a positive correlation between number of parts correctly identified and increasing age. No sex differences or Sex x Age interaction were found.

Goodgold-Edwards, S., & Cermak, S. A. (1990). Integrating motor control and motor learning concepts with neuropsychological perspectives on apraxia and developmental dyspraxia. American Journal of Occupational Therapy, 44(5), 431-9. Abstract →← Abstract

This paper reviews selected pertinent literature on the learning and performance of skilled motor acts. Information on normal motor performance is integrated with that on adult apraxia and related to common problems observed in children with developmental dyspraxia. The process of motor skill acquisition is outlined, and aspects of styles of motor organization, modes of control, premovement organization, sensory organization, and analysis of the types of errors are presented. Recommendations for clinicians working with children with developmental dyspraxia are offered.

Murray, E., Cermak, S. A., & O'Brien, V. (1990). The relationship between form and space perception, constructional abilities, and clumsiness in children. American Journal of Occupational Therapy, 44(7), 623-8. Abstract →← Abstract

The Sensory Integration and Praxis Tests (SIPT) (Ayres, 1989) were administered to 21 children with learning disabilities and 18 children without learning disabilities, aged 5 to 8 years. The children with learning disabilities were divided into two groups, clumsy and nonclumsy, on the basis oftheir scores on the Test of Motor Impairment (Stott, Moyes, & Henderson, 1984). It was hypothesized that the learning-disabled children in the clumsy group would score significantly lower than the learning-disabled children in the nonclumsy group on the six SIPT subtests that measure form and space perception and visual construction and that the nonclumsy learning-disabled children, in turn, would score significantly lower than the non-learning-disabled children. It was further hypothesized that there would be a significant correlation between the degree of clumsiness and the degree of visual perceptual and constructional deficits. An analysis of the data indicated that both groups of learning disabled children scored lower than the non-learning-disabled children on four of the six SIPT subtests. The clumsy and nonclumsy children with learning disabilities, however, differed from each other on only two subtests. The degree of clumsiness correlated significantly with three of the six subtests. The results are discussed in terms ofvaiations in perceptual and motor skills related to subtypes of learning disabilities.