Objective.

The Test ofSensory Functions in Infants

The Test of Sensory (TSFI) is one tool that occupational therapists use to iden-
tifY sensory processing disorders among infants. However,
Functions in Infants: data on the reliability ofTSFI scores with infants with
developmental delays are lacking.
Method. Test-retest reliabilities for TSFI total test
Test-Retest Reliability and subtest scores were determined with a sample of26
infants with developmental delays. All infants were be-
for Infants With tween 10 months and 18 months ofage. The test-retest
interval rangedfrom 5 days to 10 days. Magnitudes of
diffirence between test and retest scores andpercentages of
Developn1ental Delays agreement among the TSFI classification categories (i. e.,
normal, at-risk, deficient) also were determined to exam-
ine relationships between test scores.
Results. Reliability for the total test score was border-
Tracy L. Jirikowic, Joyce M. Engel, Jean C. line, with an intraclass correlation coefficient of. 78. Reli-
Deitz ability coefficients for the five subtests rangedfrom .54 to
.74. Percentage ofagreement fOr the total test classification
categories between test and retest was adequate (81 %).
Key Words: reliability of tests • sensorimotor Percentages ofagreementfor subtest classification categories
dysfunction were low, rangingfrom 58% to 68%.
Conclusion. TSFI scores should be interpreted cau-
tiordy and used only in conjunction with findings from
additional developmental assessments and clinical obser-
vations fOr injants with developmental delays.

T
he imegration and organization of sensory infor-
mation has been described as vital to learning
and adaptive behavioral processes (Ayres, 1972).
Sensory imegrarion refers co the overall process by which
the brain receives, registers, and combines sensory input
in order to generate adaptive responses co the environ-
mem (StalJings-Sahler, 1993). Disordered sensory ime-
Tracy L. Jirikowic, MS, OTRlL, is SraffTherapisr, Kwiar Child
Development Center, Seattle, Washington, and Staff Thera- gration was believed co account for some aspects of child-
pist, Fetal Alcohol Syndrome Clinic, Center for Human hood learning and behavior disorders that have been
Development and Disability, University of Washington, identified in preschool and elememary-school-aged chil-
Seattle, Washington. (Mailing address: 727 Bellevue Avenue dren (Ayres, 1972). It is now speculated that certain early
E., Seattle, Washington 98102) sensory processing mechanisms are related to and can
prediCt later learning, behavioral, and developmental dif-
Joyce M. Engel, PhD. OTRlL, FAOTA, is Assistant Professor, De-
ficulties (Greenspan, 1992; Stallings-Sahler, 1993).
partment of Rehabilitation Medicine, Occupational Therapy
The Test of Sensory Functions in Infants (TSFI)
Division, University of WashingtOn, Seattle, WashingtOn.
(DeGangi & Greenspan, 1989) is a 24-item standardized
Jean C. Deirz, PhD, OTRlL, FAOTA, is Associate Professor and assessment that occupational therapists use to identify
Graduate Program Coordinator, Department of Rehabilitation sensory processing deficits in infants. The test examines
Medicine, Occuparional Therapy Division, University of five areas of sensory function: (a) Reactivity to Tactile
Washington, Seattle, Washington. Deep Pressure, (b) Visual-Tactile Integration, (c) Adap-
tive Motor Responses, (d) Ocular-Motor Control, and
This article was acceptedfor publication January 20, 1997.
(e) Reactivity to Vestibular Stimulation. The TSFI was

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 developed for infants 4 months to 18 months of age with analyses were completed for the TSFI subtest and total
regulatory disorders (i.e., difficult temperament, irritabili- test scores.
ty), developmental delay, and risk for later learning and
Method
sensory processing disorders. Results of the test classify
the infant as normal, at-risk, or deficient in each of the Sample
five subtests and the total tesr. According to DeGangi and Infants from Seattle-area hospitals, clinics, and develop-
Greenspan (1989), scores within the normal range sug- mental centers who were more than 10 months, 1 day,
gest adequate sensory processing and reactivity; scores in and less than 18 months, 30 days of age, were recruited
the at-risk range denote suspect delays; and scores in the for this study. This particular age group was used because
deficient range suggest dysfunction. sensory dysfunction, as measured by the TSFI, has not
Although the TSFI is designed for infants as young as been demonstrated until 10 months to 18 months of age
4 months of age, the test authors suggested that it is most in infants with developmental delays (DeGangi et al.,
reliable and valid with infants 7 months to 18 months of 1988). If infants were born earlier than 37 weeks gesta-
age when used in conjunction with other developmental tional age, their corrected age was used. The age range of
assessments, clinical observations, and parent interview the sample was 10 months to 18 months, with a mean of
(DeGangi, Berk, & Greenspan, 1988). They also suggest- 14.2 months.
ed that the TSFI be used after 10 months of age for infants All infants were receiving occupational therapy or
with developmental delays or difficult temperament to physical therapy services at the time of testing. Each
best differentiate which infants may be experiencing, or infant presented with a motor delay of 25% or more than
are at risk for, sensory dysfunction. chronological age or scored below -1. 5 standard devia-
The test authors completed preliminary psychomet- tions on standardized assessments, such as the Bayley
ric research on the TSFI; however, they stated that further Scales of Infant Development (Bayley, 1969), the Bayley
information is needed to validate the initial findings
Scales of Infant Development, 2nd edition (Bayley, 1993),
(DeGangi & Greenspan, 1989). Benson and Lane (1994)
or the Peabody Developmental Motor Scales (Folio &
stated that the reliability and validity of the TSFI have not
Fewell, 1983). Infants with severe motor or orthopedic
been fully examined, and Albanese (1992) maintained
impairments (e.g., cerebral palsy, spina bifida) were ex-
that additional psychometric data are needed to support
cluded.
its clinical use. DeGangi and Greenspan's (1989) recom-
A convenience sample of 26 infants (14 boys, 12 girls)
mendations for further research included more extensive
was selected. The sample consisted of 17 Caucasian in-
test-retest reliability studies with a wider cross section of
fants, 3 Asian-American infants, 2 African-American
ages as well as examination of more extended samples of
infants, 2 Native American infants, 1 Hispanic infant, and
infants with developmental delays.
1 Nepali infant. Twelve presented with developmental
Current test-retest reliability data for the TSFI reflect
delay, 4 with prematurity and developmental delay, 4 with
the performance of infants who are typically developing.
fetal alcohol or drug exposure, 3 with Down's syndrome, 1
With a I-day to 5-day test-retest interval, DeGangi and
with tuberous sclerosis, 1 with low-grade glioma, and 1
Greenspan (1989) examined 26 infants 4 months to 18
with chromosomal deletion with retinoblastoma. Thirteen
months of age who were typically developing. Pearson
experienced motor delays only; 6 experienced motor de-
product-moment correlation coefficients ranged from .26
lays in addition to language or cognitive delays; and 7
to .96 for the five subtests, and the coefficient for the total
experienced global delays in motor, language, and cogni-
test was .81. Although the researchers selected a sample of
tive development, as determined by a 25% chronological
27 infants with developmental delays for validation stud-
age delay or scores below -1.5 standard deviations on stan-
ies, they provided no information regarding the reliability
dardized assessments.
of test scores for this group. Because Benson and Lane
(1994) suggested that infants with developmental delays
Procedure
may present with greater variability in their responses to
sensory stimuli, which could affect score stability, thus The TSFI was administered by the first author in accor-
further supporting a need to examine the test-retest relia- dance with the standardized procedures described in the
bility of the TSFI for infants with developmental delays. manual. The author had 3 years of experience in pediatric
The purpose of this study was to examine the TSFI occupational therapy. Consistent with these procedures,
test-retest reliability, the magnitudes of difference be- each infant was assessed for reactivity to tactile deep pres-
tween test and retest scores, and percentages of agreement sure, visual-tactile integration, adaptive motor responses,
between test and retest categories (i.e., normal, at-risk, ocular-motor COntrol, and reactivity to vestibular stimula-
deficient) for infants with developmental delays. All three tion in the presence of a parent or familiar caregiver. Each

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 infant was tested in a quiet room within the home or clinic. Control subtests because the data were not normally dis-
Auditory or visual distractions were minimized. Each tributed.
infant was seated on a mat, blanket, or parent's lap during The magnitudes of difference between individual test
test administration. Before testing, the infant's socks and and retest scores also were determined. The magnitude of
shoes were removed and shirt sleeves rolled up. EffortS difference (i.e., retest measurement minus test measure-
were made to ensure that the infant was in an optimal ment) provides precise information regarding the actual
behavioral State before testing. An infant who was ex- point spread between test and retest scores; this followed a
tremely fussy or irritable, as indicated by inconsolable cry- procedure similar to that Wescott, Crowe, Deitz, and
ing, before the initiation of the test was rescheduled. The Richardson (1994) used in their research on the Pediatric
test sessions ranged from 15 min to 25 min. Clinical Test of Sensory Interactions for Balance. Percen-
The second test administration occurred 5 days to 10 tages of agreement between test and retest classification in
days after the first administration. Each infant was tested each of the three possible categories also were determined.
by the first author under the same conditions as the first This measure was added to provide clinicians with an esti-
session. Conditions included testing in the same environ- mate of classification consistency because score changes
ment, at approximately the same time of day, in the pres- do not necessarily imply classification changes.
ence of the same caregiving adult or parent, in the same
test position (i.e., on a mat, on parent's lap), and with the Results
same procedures as those just described. Descriptive statistics and reliability coefficients for test
Scoring procedures followed those outlined by De- and retest scores are presented in Table 1. Table 2 reports
Gangi and Greenspan (1989). The infants received a nu- the magnitudes of difference between test and retest scores
merical score that was based on specific behavioral per- for each subtest and the total test. For example, note that
formance cri teria for each test item. Item scores were for the first subtest, Reactivity to Tactile Deep Pressure, 21
then summed for each subtest, and subtest scores were infants' scores either stayed the same or changed positively
added to achieve a total score. Scores for the total test or negatively by one point, 1 increased by two points, 1
and each subtest were then classified as normal, at-risk, or increased by four points, and 3 decreased by two points.
deficient. Table 3 summarizes the changes among normal, at-risk,
To help establish confidence in TSFI administration or deficient categories between the test and retest inter-
and scoring methods, interrater agreement was estab- vals.
lished between the examiner and another occupational
Discussion
therapist with 3 years of pediatric experience. Before data
collection, item-by-item agreements of.96 and 1.00 were Test-retest reliability of the TSFI total test score was bor-
determined by testing two infants who were typically derline (ICC = .78), whereas test-retest reliability for the
developing. During data collection, interrater agreement subtests was low, with reliability coefficients ranging from
checks were performed on 2 of the 26 infants in the sam- .54 ro .74. The Reactivity to Tactile Deep Pressure subtest
ple, with an average item-by-item agreement of .94. had the highest reliability among sub tests (rs = .74), fol-
lowed by the Visual-Tactile Integration (rs = .67) and
Data Analysis Ocular-Motor Control (rs = .67) sllbtests, the Reactivity
Descriptive data for test and retest were compiled and to Vestibular Stimulation subtest (ICC = .63), and the
reviewed in conjunction with scatter plots to decide wheth- Adaptive Motor Responses subtest (rs = .54). These find-
er to use parametric or non parametric indexes of reliability. ings suggest that TSFI total test scores are generally more
Because the data were approximately normally distributed stable than individual subtest scores.
for the total test and the Reactivity to Vestibular Stimu- The magnitudes of difference between test and retest
lation subtest, intraclass correlation coefficients (ICCs) scores varied among the subtests and the rotal test. Be-
were selected. The cwo-way, random-effects, repeated- cause of the variable potential point spread among test
measures model was used because it considers differences and subtest scores, results are discussed individually for
between test and retest scores to be sources of error (Paul- the total test and each subtest. On the total test, which
son & Trevisan, 1990). It is also congruent with the typi- has a potential score range of 0 to 48, 21 infants scored
cal clinical practice of basing infant scores on one admin- within ±4 points between test and retest. The remaining 5
istration of the test rather than on the average of two or infants demonstrated greater variation with their retest
more administrations of the test (Tinsley & Weiss, 1975). scores, deviating by 2: 5 points but::; 11 points. However,
A Spearman rank order correlation was used for the Re- when comparing score changes for these infants with the
activity to Tactile Deep Pressure, Adaptive Motor Re- actual classification category changes, only 1 moved ro a
sponses, VisllaJ-Tactile Integration, and Ocular-Motor different category (i.e., from deficient to at-risk). The

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 Table 1
Descriptive Statistics and Reliability Coefficients for TSFI Subtest and Total Test Scores
Test Highest Possible Scote M Median Low/High SD Reliabiliry Coefficient
Total Test
Test 48 38,15 38.50 25/48 6.38 .78 a
Retest 48 3877 38.50 26/47 650
Reactiviry to Tactile Deep Pressure
Test 10 7.77 8.00 2/10 2.03 74 b
Reresr 10 754 8.00 2/10 1.82
Adaptive Moror Responses
Tesr 15 11.92 13.00 3/15 2.68 .54 b
Rerest 15 12.23 13.00 4/15 2.55
Visual-Tactile Integtation
Test 12 8.00 8.00 3/10 2.06 .67 b
Retest 12 8.42 9,00 4/10 1.88
Ocular-Motor Connol
Test 2 1.31 1.00 0/2 0.74 .67 b
Retest 2 1.31 2.00 0/2 0.84
Reactiviry ro Vestibular Srimularion
Test 12 9.19 10.00 5/12 2.26 .63 a
Retest 12 9.19 10,00 5/12 2.23
Note. N = 26; rerest inrerval = 5-10 days. TSFI = Test for Sensory Funcrions in Infants.
aIntraciass correlation coefficient.
bSpearman rank ordet coefficient.

other 4 fluctuated within the deficient category. Thus, test would reflect a more typical response to tactile input,
despite a wide point spread, it appeared that the classifica- suggesting that some of the infants may have accommo-
tion categories for the total test remained relatively stable. dated to the test stimuli on the second administration.
No specific patterns emerged regarding the subtest perfor- No other obvious patterns emerged regarding the distrib-
mance of these last 4 infants because mild to moderate utions of magnitude of difference between test and retest
variabilities in the point spreads and classification cate- scores for the remaining subtests. Magnitude of differ-
gories were seen in all domains. It also should be noted ence between test and retest scores were relatively evenly
that these 4 infants with the highest variability were distributed in both directions.
reported by their caregivers to be more tired or irritable The findings suggest that the total test classifications
during one of the test sessions. were more stable than the subtest classifications. For the
On the Visual-Tactile Integration subtest, 10 infants total test, 21 infants were classified in the same category
scored one to three points higher between test and retest (i.e., normal, at-risk, deficient) on the test and retest ses-
versus only 2 scoring lower. A higher score on this sub- sions. The percentages of agreement for the sub tests be-

Table 2
Magnitude of Difference Between Test and Retest TSFI Scores
Point Spread
Test < -7 -6 -5 -4 -3 -2 -1 0 2 3 4 6 >7
Reacriviry ro Tactile Deep Pressure
n 3 7 12 2 1 1
% 11.5 26.9 46.2 7.7 3.8 3.8
Adaptive Motor Responses
n 1 2 4 8 6 3 I I
% 3.8 7,7 15.4 30.8 23.1 11.5 3.8 3.8
VisuaJ-Tactile Integration
1 I 14 4 2 4
%" 3.8 3.8 53.8 15.4 7.7 15.4
Ocular-Motor CancroI
I 3 17 5
%
" 3.8 11.5 65.4 19.2
ReaC(iviry ro Vestibular Stimulation
n 2 3 3 13 1 2 1 1
% 7.7 11.5 11.5 50.0 3.8 7.7 3.8 3.8
Total Test
2a I 3 3 3 I 6 4 1 2b
"
% 7.7 38 11.5 11.5 11.5 3.8 23.1 15.4 3.8 7.7
Note. N = 26. TSFI = Test fat Sensory Functions in Infants.
aThe magnitudes of difference fat these scores were -7 and -I 1,
b-rhe magnitudes of difference for these SCates were 9 and 10,

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 Table 3
Classification Changes Between Test and Retest TSFI Scores
Test/Retest

Norma1l Notmal/ Normal/ At-Risk! At-Risk/ At-Risk/ Deficient/ Deficient/ Deficient/

TSFI Test Normal At-Risk Deficient At-Risk Normal Deficient Deficient At-Risk Normal
Reactivicy to Tactile Deep Pressure 4 6 0 3 2 2 8 1 0
Reactivicy to Vestibular Stimulation 9 1 1 2 1 2 7 1 2
Adaptive Motor Responses 2 2 1 4 3 2 9 2 I
Visual-Tactile Integration 9 I 1 5 4 1 3 0 2
Ocular-Motor Control 11 0 1 4 3 3 2 2 0
Total Test 7 0 0 I 1 1 13 3 0

Note. N = 26. TSFI = Test fot Sensocy Functions in Infants.

tween test and retest ranged from 58% to 69%. Agree- Additional information regarding the behavior of the
ment was highest for the Reactivity to Vestibular Stimu- infants during the test performance also should be consid-
lation subtest (69%), the Visual-Tactile Integration sub- ered when interpreting results. Infants who were reported
test (65%), and the Ocular-Motor Control subtest (65%), by their caregivers as tired, irritable, or fussy during one of
followed by the Reactivity to Tactile Deep Pressure subtest the test sessions generally performed more poorly on one
(58%) and the Adaptive Motor Responses subtest (58%). session than the other. Despite variabili ty in the actual
Again, subtest scores were somewhat unstable; therefore, total test scores, these infants' classification categories
caution is recommended when using these results. A de- remained relatively stable. No specific diagnostic patterns
tailed analysis of changes between total test and subtest were noted in this group of infants; however, all of them
categories is provided in Table 3. scored in the deficient performance range for the total
In comparison to DeGangi and Greenspan's (1989) test. None of these infants met criteria for exclusion be-
results from preliminary studies with the TSFI, reliability fore testing (i.e., they did not demonstrate inconsolable
coefficients from the current study were slightly lower on crying or fussiness); instead, their irritability and fatigue
the total test, the Reactivity to Tactile Deep Pressure sub- appeared to increase during testing. This suggests that the
test, and the Adaptive Motor Responses subtest. Relia- infants who demonstrated sensory dysfunction were even
bility coefficients from our study were substantially lower less able to cope with the test stimuli and test demands
on the Visual-Tactile Integration and Ocular-Motor Con- when factors such as fatigue or illness were present. There-
trol subtests, and our reliability coefficient for the Reac- fore, clinicians may want to ask caregivers about the in-
tivity to Vestibular Stimulation subtest was higher. When fant's health, behavior, and mood before testing and sched-
comparing the results from these two studies, it is impor- ule testing or provide descriptive information accordingly.
tant to note several differences. DeGangi and Greenspan It also seemed that infants who appeared to have more
examined infants who were typically developing, most of motor deficits performed most poorly on the Visual-
whom were 4 months to 6 months of age; analyzed the Tactile Integration and Adaptive Motor Responses sub-
data with Pearson product-moment correlations; and used tests, both of which require more refined motor responses
more than one examiner to test the infants. (e.g., removing a sticker from the hand or a toy placed on
From their preliminary test-retest studies, DeGangi the stomach). The scores on these subtests with infants
and Greenspan (1989) concluded that decisions regarding wirh mowr deficits may reflect both sensory and motor
infants' vestibular and adaptive motor functioning should performa.nce rather than jusr sensory function, meriting
not be made until test-retest results confirm normalcy or further investigation.
dysfunction. The borderline reliability coefficients and
magnitudes of difference between test and retest scores Limitations
from this study also support these conclusions as well as The limirarions of rhis study included rhe variable narure
suggest that the clinician interpret all subtest scores with of the tested behaviors themselves, which can be affected
caution. In addition, because of the low reliability coeffi- by factors such as the infant's state of arousal, health, and
cients for the subtests, it is recommended that subtest farigue. In addition, rhe small hererogeneous san1ple lim-
scores be used with extreme caution for diagnosric pur- irs the generalizability of rhe results.
poses and documenting change over time. However, the
clinician could have some confidence regarding the stabil- Conclusion
ity of normal, at-risk, or deficient classification decisions Results of rhis srudy suggest thar rhe resr-retest reliability
for rhe toral test. However, funher study is needed In for rhe TSFI roral test scores is borderline and that the
order to evaluate the validity of these decisions. test-retest reliabilities for the subtest scores are low. Per-

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 centages of agreement for classification categories between References
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Universiry of Washingron, SeatrIe, Washington. atrics, 14(1), 1-21.

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