JEAN AYRES CLINICAL OBSERVATION TEST

This test was designed by Jean Ayres and consists of 19 items; it allows observing postural
mechanisms, hand and eye coordination and other neuromuscular conditions related to
learning and behavior.
It is rated from 1 to 3, being 1 normal, 2 slightly deficient and 3 deficient. It is applicable to
children over four years old up to 12-13 years old.

1. HYPERACTIVITY Vs. DISTRACTIBILITY

Behavior pattern characterized by an excessive degree of motor activity associated with
inattention and sometimes impulsivity which are inappropriate for the child's developmental
level.

Mode of assessment: The child is observed for unusual levels of activity during the
assessment process, in play, in the classroom, and for family and school information.

Justification: It provides information about sensory functioning and integration, sometimes

associated with tactile defensibility; it also allows determining the child's environmental
adaptability and psychosocial behavior.

Qualification criteria:
1. Normal activity
2. Slight hyperactivity
3. Definite hyperactivity

2. TACTILE DEFENSIBILITY
It is an excessive response of the tactile system to its stimulation, i.e. it is not able to
modulate the information.

Mode of evaluation: The evaluation process can be observed by identifying whether the
child allows contact, being touched, rubbed, hugged and the reaction he/she presents
when in contact with the different equipment and its textures. If the child presents tactile
defensibility, he/she overreacts with emotional manifestations, aggressiveness and
rejection of the stimulus.

Rationale: Provides information on sensory integrative processing at the tactile, reticular or

limbic level, indicating a deficit in sensory integration.

Qualification criteria:
3. Tolerates a variety of tactile stimuli
2. It presents some adverse reactions to tactile stimulation.
1. Over reacts to tactile stimulation. Does not tolerate.

3. POSTURAL TONE
Depends on muscle tone.

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Mode of assessment: It is assessed through muscle tone by palpation, observation and
mobilization.

By palpation: Being the child in any position Ia muscle mass is touched and the degree of
hardness is observed, if it is soft is predicted hypotonia (decrease in tone) or atony
depending on the degree, if it is very hard hypertonia. The eutonia is palpated as a firm
mass that facilitates mobilization of the segment.

By observation: The alignment position of the body segments is observed. MMSS: Arm in
90 degree flexion, fingers extended, forearm supinated. The elbow joint is checked to see if
the elbow joint is:
Hyperextended - Hypotonic
Slightly flexed - Hypertonus
Proper alignment - Eutonia

At shoulder level: Raise the arm up to 180 degrees, anterior elevation.

If the arc is greater - Hypotone
If the arc is not complete - Hypertonus
If the arc is normal - Eutonia

Scarf signs: Head in neutral, arm in 90 degrees of flexion, elbow in flexion, forearm in
pronation, touching the shoulder of the opposite side.
If the elbow passes the chin - Hypotonus
If it does not reach the chin - Hypertonus
If aligned with the chin - Eutonia

In trunk: Observe the posture in standing position.

If there is marked lordosis - Hypotonus
If there is little lordosis - Hypertonus
Normal posture - Eutonia

At the level of MMII: Observe in standing position the knee joint.

If there is hyperextension - Hypotonus
If there is slight flexion - Hypertonus
If there is thigh and leg alignment - Eutonia

In hip: Observe the joint in supine or bipedal position with legs extended.
If there is hyperextension - Hypotonus
If there is slight flexion - Hypertonus
If there is alignment of the iliac crests - Eutonia
To mobilization: Passive movements of the segment are performed rhythmically with full
arc.
Example: Shoulder: flexion, extension, ABD, ADD. Observe for resistance to
movement.

Elbow: flexion and extension.

Signs of razor or cogwheel are observed.

If the arc of movement is not complete: Hypertonus and in major cases spasticity.

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If the arc of movement is greater: Hypotone is observed if there is ligamentous hyperlaxity.

It can also be evaluated by observing the posture in general. Child in bipedal position.
Head and trunk aligned, arms extended along the body, leaning or sticking to a grid or wall.
The alignment of the head, neck, shoulder girdle, pelvic girdle, knees, ankles, alignment
and symmetry of the spine is checked in each of the anterior, posterior and lateral planes.

Hypotonia: protruded shoulders, winged scapulae, increased lumbar lordosis, protruded

abdomen and hyperextension of the knees.

Hypertonia: Retracted shoulders, increased dorsal kyphosis.

Equipment, material and tool: dorsal kyphosis augmentation.

Justification: Provides vestibular and proprioceptive information that determines postural

mechanisms, balance and alignment of segments in all planes. Evidence of poor postural
tone indicates a motor impairment.

4. EYE PREFERENCE
Mode of application: The child sitting comfortably, with feet on the floor and hands free on
the thighs if the child wears glasses should remove them. The therapist sits in front of him
and the following sequence is followed:

> Look through a circle formed by the examiner's hands 15 cm away from the midline.
> Give a sheet of paper with a hole 8 to 10 cm in diameter; the child should hold it and
look through it.
> The child is given a kaleidoscope, cone or cylinder to look through.
> The child is instructed to look at the two ends through a circle formed by his fingers.
> The child is asked to wink.

In each test, the hand used to hold the object and the eye used by the child to look through
the objects presented on the midline are recorded.
Equipment, tool, material: chair, cone, kaleidoscope or cylinder, sheet with small hole.

Rationale: Lack of eye-hand correlation may be suggestive of poorly developed laterality

and interhemispheric connection deficit. As well as difficulties in reading and writing, visual
fixation of objects and the whole area of visual perception.

5. EYE MOVEMENTS
Ability to follow objects with the eyes in different planes of movement (horizontal, vertical,
diagonal and circular).

Mode of application: The child sitting comfortably with feet on the floor and hands free on
the thighs, the child is asked not to move the head leaving the eyes moving. Normal 4-year-
olds should be able to dissociate head and eye movements.
With a flashlight or pencil a movement is made across the child's visual field starting from
the midline in different directions and at a distance of approximately 20 to 25 cm from the
bridge of the nose; the movement of the eyes is observed.

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Equipment, tool, material: Flashlight or pencil placed on the eraser side, can be adapted
with a brightly colored pin that catches the child's attention.

Justification: This test allows to observe:

> Oculo-cephalic dissociation (eye movement independent of the head). If the child
moves its head, it is evaluated in another position, such as leaning against the wall.
> Midline crossover.
> The stimulus is momentarily lost and relocalized when it reaches the midline . This
may suggest a laterality problem or interhemispheric miscommunication.
> Pursuit in general (if performed at the full arc of movement in the
horizontal, vertical, diagonal and circular planes).
> Ocular fixation or rapid localization (assessed by asking the child to look at the
pencil and then to the therapist quickly movement of different planes).
> Presence of nystagmus (this test allows to observe the presence of problems in
lateralization, difficulties in reading and rapid location of objects). It determines what
vestibular and visual information the child possesses and the motor planning
capacity at eye level or ocular motor praxis.
> Ocular convergence (ability to bring one or both eyes individually closer to the
midline; observed if there is a difference between the right and left eye. It provides
information about the visual, vestibular and motor planning of the eyes. Extreme
gaze nystagmus can be identified in normal children. It allows detecting problems of
laterality and interhemispheric independence and reading difficulties).

Qualification criteria:
Each of the above parameters is rated:
3. Normal
2. Slightly irregular
1. Deficient
A difference is established between the right and left eye.

6. ABILITY TO E3ECT SLOW MOVEMENTS

Mode of application: Child in bipedal position with shoulders in ABD, elbows, hands and
fingers in extension parallel to the floor; the examiner asks the child to flex the elbows and
to touch the shoulders with the hands and to return to the initial position. A sequence
should take approximately 5 seconds to bring the hands to the shoulders and 5 seconds to
return to the starting position. It must first be performed by the O.T. (4 times) and the child
must imitate it.

Justification: Brinda information on interhemispheric integration, the

proprioceptive processing, body schema and postural mechanisms.

Qualification criteria:
3. Normal
2. Slightly uneven takes 13 seconds
1. Irregular, too fast or takes longer than 13 seconds with problems to execute the
movement.

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 7. DIADOCENCIA
Mode of application: The child and Ia therapist sit facing each other with elbows bent,
arms glued to the trunk and hands on the thighs. The therapist performs the
pronosupination movement quickly and asks the child to imitate her, telling her to do it
quickly. The number of times the palms strike the thighs is counted in seconds (usually 10);
first with one hand, then with the other, then with both at the same time. It is observed if
there is incoordination, associated reactions and asymmetries. Children will be able to have
continuous forearm rotation up to the age of 8 years.

Equipment, tools, material: Chair

Justification: Provides information on motor planning; bilateral integration and postural

mechanisms.

Scoring criteria: The number of times the palms strike the thighs in 10 seconds is
observed.
Right hand, left hand and simultaneously.

3. Perform rapid alternating movements of 8 to 10 minutes.

2. Performs alternating movements without rapidity, less than 8
1. Does not perform alternating movements.

8. TOUCHING FINGERS WITH THE THUMB OR OPPOSING THUMBS

Ability to organize rhythmic movements of digital opposition.

Mode of application: The child is asked to touch with the thumb the other fingers starting
from the index finger to the little finger sequentially, first with one hand, then with the other
and then with both hands. It should be performed initially with the eyes open and then
closed. Children 6 years of age should be able to perform 2 or 3 series of unilateral thumb-
finger touches and those 8 years of age and older a greater number of series.

Justification: Provides information on motor planning, bilateral integration and postural

mechanisms.

Qualification criteria: Right hand, left hand and simultaneously.

3. Perform rapid alternating movements of 8 to 10 minutes.
2. Performs alternating movements without rapidity, less than 8
1. Does not perform alternating movements

The quality and speed of the movements are observed. If it presents synkinesias or
associated movements.

9. TONGUE - LIPS MOVEMENTS

Mode of application: Tongue protrusion is evaluated, i.e. the child should take the tongue
out of the mouth and keep it out for 3 seconds, bring it up and touch the upper lip, down to
the lower lip, to the sides the right and left labial commissures; the child is asked to roll and
unroll the tongue, make circles with the lips and whistle.

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Justification: The buccolinguofacial region and the hand are the parts of the body that
perform the finest and most complex movements of the body requiring high cortical
representation. Provides information on motor planning, bilateral integration, spatial
management and self-recognition.

Evaluation criteria: Right side, left side simultaneously.

3. Performs movements in an appropriate and coordinated manner
2. Performs movements with slight deficiency
1. It does not perform the movements or does so very poorly.

The quality and speed of the movements are observed; if synkinesias or associated
movements are present.

10. COCONTRACTION
Ability of simultaneous action between agonist and antagonist muscles to maintain a body
position.

Mode of application: It is evaluated in head, trunk, MMSS and MMII. The child is placed in
a seated position, head and trunk aligned without support on the backrest, feet on the floor,
elbows bent and free hands resting on the thighs.

For head: Head in neutral (Resistance is applied by placing one hand on the forehead and
the other on the occipital region and movements are performed backwards, forwards,
sideways and circular).

For trunk: Trunk aligned and unsupported (T.O. applies resistance to the shoulders and the
child must keep the trunk aligned).

MMSS and MMII: Semi-flexed position locking elbows and knees respectively (child grasps
thumbs O.T. and she takes the child by the wrists, pushes and pulls him/her by making
small semicircular movements, first simultaneously and then alternating in a time of 2 to 3
seconds, to determine the strength in shoulders and elbows more proximal than distal; if
the child does not resist, the test is repeated to determine if there is a decrease in muscle
tone or hypotonia).

The examiner exerts resistance and the child must maintain the position and inhibit passive
mobilization of the evaluated segment.

Equipment, tools and material: Chair

Justification: It provides information on the state of tone, vestibular and proprioceptive

function as well as postural mechanisms.
Therefore, the presence of alteration indicates deficits in balance, postural mechanisms
and motor skills.

Qualification criteria:
3. Normal
2. Slightly deficient or fair

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 1. Poor 0 bad

11. POSTURAL INSECURITY

It is the presence of fear before postural changes caused by poor postural information
received by poorly integrated vestibular and proprioceptive afferents.

Mode of application: It can be observed in all motor attitudes of the child. He/she may be
asked to climb to a high surface; generally when there is postural insecurity, he/she refuses
and in case of doing so, he/she manifests uncomfortable and adverse feelings such as
shouting, crying, fear, anxiety and some associated reactions such as increased tone and
vertigo.

Equipment, tools and materials: Bench, chair, ladder, swing.

Justification: Provides information about the status of the tone, the performance
vestibular, proprioceptive, visual and indicates the degree of postural integration, its
presence alters the motor plane, postural mechanisms and balance.

12. POSTURAL MOVEMENTS IN THE BACKGROUND

These are subtle spontaneous adjustments of position, involving open hand movements.

Mode of application: They can be observed by having the child reach with his hands for a
distant object, pull or push it; it is identified as the MMII, automatically adjust so that the
arms do their job efficiently. It can also be assessed using paper and pencil or by having
the child connect two dots on the board.

Equipment, tools and materials: desk, chair, board, pencil, marker, different objects and
paper.

Justification: Provides information about vestibular, proprioceptive and visual functioning

and integration, and indicates difficulty in postural mechanisms.

Individuals with postural adjustment deficits have difficulty dancing and playing games.

Qualification criteria:
3. Normal
2. Slightly deficient
1. Deficient

13. EQUILIBRIUM REACTIONS

Mode of application: Child in different positions on the balance board or rocker (prone,
supine, quadruped, kneeling, squatting, sitting and bipedal). The therapist provokes a
lateral or anterior-posterior stimulus. The response is given according to the position (there
is alignment of the posture with slight protective extension of the extremities, increasing the
polygon of sustentation and maintaining the posture).

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Justification: Provides information on vestibular, proprioceptive and visual function and
indicates difficulties in postural mechanisms. The absence of balance reactions
demonstrates a dysfunction in postural control and gravitational security.
Symmetry and asymmetry of movement, permanence of increase or decrease of tone and
bilateral reactions can be observed.
Qualification criteria:
3. Presents normal reactions to the stimulus
2. Responses are slightly observable
1. No answers

14. UPPER LIMB PROTECTIVE EXTENSION

Mode of application: Child in kneeling or seated position, the examiner positioned from
behind pushes the child forward from the scapular region. MMSS extension response in a
protective manner. It is evaluated anteriorly, posteriorly and laterally. The child can also be
evaluated while in prone position on the Bobath ball, the therapist takes the child by the
ankles and gives an impulse, the child's response is to protect himself/herself. If there is no
protective response it should be launched in the Shkoder.

Equipment, tools and material: Mat.

Justification: Provides vestibular, proprioceptive and postural mechanism information. The

absence of this pattern indicates difficulties in postural control and balance reactions.

Qualification criteria:
3. Features protective arm extension
2. Starts the pattern
1. No protective reaction

15. SHILDER ARM EXTENSION POSTURE

Mode of application: The child is placed in a bipedal position with arms extended forward,
fingers extended and separated, feet together and eyes closed.

For the Shilder 1 test: The child is asked to count to 20 slowly (if the child is very young, the
therapist counts), and is observed for choreoathetocic movement, hyperextension of the
elbows or trying to stabilize with hands together, loss of balance, difficulty in keeping the
eyes closed, or if one arm is raised or lowered (the dominant hand may be raised).

For the Shilder 2 test: In the same position as above, the therapist turns the child's head to
the right and then to the left. The response is the maintenance of the extensor position of
the arms, it is observed if there is excessive rotation of the trunk, resistance to the rotation
of the head (asymmetric tonic nuchal reflex), differences between right and left or rotation
of the arms towards the side of rotation of the head.

Equipment, tools and materials: mat or solid surface or on the floor.

Justification: The two tests give vestibular, proprioceptive and postural mechanism
information. They may indicate difficulty in performing segmental head and body
movements.

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Qualification criteria:
3. Normal
2. Slightly irregular
1. Deficient

16. PRONE EXTENSOR OR PIVOT POSITION

Mode of application: Child in prone position, MMSS in external rotation at the shoulders
and elbows flexed, MMII in extension and forehead resting on the mat. The child is asked
to lift the head, upper trunk, arms and legs without the knees touching the mat or the floor
(a maximum flexion of 30 degrees is allowed) and to hold the position for approximately 20
seconds.
It can be demonstrated or placed in position if necessary, if the latter occurs the child
should unload and then assume the position. Normal 4- and 5-year-olds may be unable to
assume this position or hold it for only a short time.

Equipment, tools and material: Mat.

Justification: Provides information on the state of extensor muscle tone, proprioceptive

function, vestibular integration, co-contraction and postural mechanisms.

Qualification criteria:
3. Assume and maintain the position for 20 seconds without effort.
2. Assume and hold the position for 10 to 20 seconds with moderate effort.
1. It does not assume Ia position Ia supports it for less than 10 seconds.

17. SYMMETRICAL NUCHAL TONIC REFLEX

Mode of application: The child is placed in a prone or quadruped position. Its head is
stretched and strapped. The following response was observed:
For flexion, increased flexor tone in MMSS and extensor in MMII.
For extension, increased extensor tone in MMSS and flexor tone in MMII.

Equipment, tools and material: Mat or stretcher.

Justification: The reflection provides us with information about the state of the tone, the
functioning of the visual, vestibular and proprioceptive systems. Its presence demonstrates
a disorder in the postural mechanisms; that is to say that the integration is at the level of
the brain stem.

Qualification criteria:
1. No change in flexor or extensor tone of the segments.
2. Slight change in flexor and extensor tone of MMSS and MMII.
3. Marked change in the position of the flexor and extensor tone of the segments.

18. ASYMMETRIC CERVICAL TONIC REFLEX

There are two ways to evaluate the first one is in quadrupole position and the second one
in antitonic position.

> Quadruped position:

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Mode of application: The child is placed in a quadruped or prone position, the head is
turned or rotated sideways. No changes should be observed in the articular segments of
MMSS and MMII. If the reflex still persists, extension of the upper and lower limb on the
side towards which the head is broken and flexion of the opposite hemisphere (fencing
position) will be identified in the child.

Equipment, tools and material: Mat or stretcher.

Justification: The reflex provides us with information about the state of tone, the
functioning of the visual, vestibular and proprioceptive systems. Its presence demonstrates
a disorder in the postural mechanisms; that is to say that the integration is at the level of
the brain stem.

Qualification criteria:
1. No flexion during passive head rotation
2. Slight flexion when passively rotating the head
3. Marked flexion when passively rotating the head.

> Antitonic position:

Mode of application: The child is placed in a quadruped position and is asked to raise his
head, extend and raise his right leg, raise his left arm and bend his elbow placing his hand
on his waist on the same side and finally turn his head to the left side and place his chin on
the shoulder of the same side. You must assume and maintain balance in the position for a
few seconds.

Material: mat.

Justification: Provides information about the status of the tone, the performance
vestibular, proprioceptive, bilateral integration, lateralization, integrity in the communication
of both hemispheres and postural mechanisms.

Qualification criteria:
3. Can assume position and maintain balance
2. Assumes the position with great difficulty
1. Cannot assume the position

19. FLEXOR SUPINATUS PATTERN

Mode of application: Child in supine position with flexion of the head and trunk, arms
crossed over the chest, ankles crossed, flexion of the hips and knees. The forehead should
be as close as possible to the knees. Resistance is applied to the head and knees: the
response is the maintenance of the position in the face of resistance. Children 8 years old
can hold from 20 to 30 seconds: that is, depending on the age, the dwell time is measured.

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Equipment, tools and material: Mat.

Justification: It allows observing the state of flexor muscle tone, if the child can assume
patterns globally, if he/she maintains them and if they are resisted. It provides information
on proprioceptive function, vestibular, bilateral integration, contraction and postural
mechanisms.

Qualification criteria:
3. Assumes and maintains the position for 20 seconds without effort.
2. Assumes and holds position for 10 to 20 seconds with moderate effort.
1. Does not assume position or hold it for less than 10 seconds

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 CLINICAL OBSERVATIONS TEST

NAME: EVALUATION DATE:

COURSE: _____________________ EVALUATOR: ___________________________

1. HYPERACTIV/ 2. DEFENSB.TACTIL: 3. MUSCLE TONE

DISTRAC: 3. No response +. Hypertonic
3. Normal Activity 2. Any response 3. Normal
2. Slight hyperactivity 1. Defensive 2. Mild Hiccups.
1. Def. Hyperactive response. 1. Hypotonic
4. OCULAR PREFERENCE: 0J0 HAND
> Look through a circle formed with your fingers at 15 cm. DI DI
> Look through a hole in a piece of paper DI DI
> Look through different objects. DI DI
Ex. Cone, kaleidoscope
> Look at extremes through spaces formed by their hands. DI DI
> Stinging the eye. DI DI

5. EYE MOVEMENTS:
Midline crossover Pursuit in general Convergence Quick location
3. Normal 3. Normal 3. Normal 3. Normal
2. Lig. Irregular 2. Lig. Irregular 2. Lig. Irregular 2. Lig. Irregular
1. Def. Deficient 1. Def. Deficient 1. Def. Deficient 1. Def. Deficient
DIFFERENCES D/I

6. ABILITY TO PERFORM SLOW MOVEMENTS

3. Normal
2. Slightly irregular
1. Irregular - too much fast

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 7.Movements
DEADOCOCINECIA: Changes in
RIGHT Trunk LEFT Head Discomfort
SIMULTANEOUS
Choraoathetosicosposition
Number of times in
3. Normal rotation resistance 3. Normal
3. Normal
MMSS
The hands hit the 2. Lig. Deficient 2. Lig. Deficient 2. Lig. Deficient
3. Normal 3. Normal
Thighs
2. Lig.inDefic.
10 seconds2. Lig. Defic.
1. Def. Deficient
3. Normal1. Def. Deficient
3. Normal 1. Def.3.Deficient
Normal
1. Def. Defici. 1. Def. Defici. 2. Lig. Defic. 2. Lig. Defic. 2. Lig. Defi.
1. Def. Defici. 1. Def. Defici 1. Def. Def
8. FINGER TOUCHING: RIGHT LEFT SIMULTANEOUS
WITH THE THUMB 3. Normal 3. Normal 3. Normal
2. Lig. Deficient 2. Lig. Deficient 2. Lig. Deficient
1. Def. Deficient 1. Def. Deficient 1. Def. Deficient

9. MOVEMENT: RIGHT LEFT SIMULTANEOUS

TONGUE - LIPS 3. Normal 3. Normal 3. Normal
2. Lig. Deficient 2. Lig. Deficient 2. Lig. Deficient
1. Def. Deficient 1. Def. Deficient 1. Def. Deficient

10. CO-CONTRACTION 11. SUPINE POSTURAL 12. POSTURAL

(ARM, SHOULDER AND INSECURITY: MOVEMENT IN
NECK): THE
BACKGROUN
3. Normal 3. Normal 3. Normal
2. Lig. Defjciente 2. Lig. Defjciente 2. Lig. Defjciente
1. Def. Deficient 1. Def. Deficient 1. Def. Deficient

13. EQUILIBRIUM REACTIONS:

PRONO QUADRUPEDA SEDENTE

3. Normal 3. Normal 3. Normal
2. Slightly Deficient 2. Slightly Deficient 2. Slightly Deficient
1. Def. Deficient 1. Def. Deficient 1. Def. Deficient

14. EXT. PROTECTIVE OF MMSS:

3. Normal
2. Slightly Deficient
1. Def. Deficient

15. SCHILDER'S ARM EXTENSION POSTURE:

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16. PRONE EXTENSOR PATTERN:
3. Holds it for 20 seconds or more with moderate effort.
2. Hold it for 10 to 20 seconds with great effort.
1. Holds it for less than 10 seconds or cannot do it.

17. SYMMETRICAL RTC (HEAD FLEXED AND EXTENDED)

No change in flexion or extension of the joints.
2. Slight change in the position of the joints.
1. Marked change in the position of the joints.

18. ASYMMETRIC RTC:

A. Quadruped position:
3. There is no flexion when the head is passively rotated.
2. Slight bending during passive head rotation
1. Marked flexion when passively rotating the head.

B. Anti-tonic position:
3. Can assume position and maintain balance
2. Assumes the position with great difficulty
1. Cannot assume the position.

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