147
Association of Motor Impairment with Various Types of Behavior Disturbance
Denis H. Stott, PhD
Many models of learning disabilities stress a particular disability as the core from which school failure and associated interpersonal problems derive. The disability is sometimes considered to be neurologically based though socalled process-deficit models are similar in their single disorder focus. In this article, Stott produces evidence for a multiple impairment theory. The position suggests that any one handicapping condition makes the child more prone to problems in other areas — the probability of additional problems increases disproportionally with each succeeding disability. The notion has intuitive appeal and opens new avenues for research. — G.M.S. The incidence of behavior disturbance among school-aged pupils was surveyed to explore the relationship of motor impairment to the core syndromes of disturbed behavior as identified by the Bristol Social Adjustment Guides. No excess of motor impairment was observed with the underreactive types of maladjustment. Among the overreactive types, Inconsequence, the failure to monitor the consequences of actions, showed a strong concordance with motor impairment. The relation of this finding to the Strauss syndrome and its implications for assessment of learning disabled and behavior disturbed children are discussed.
I
n boys placed on probation, Stott (1962) found a consistent relationship between disturbed behavior and chronic health problems. Using the Bristol Social Adjustment Guides 34
(BSAG), he found that maladjusted probationers had on the average over twice the incidence of chronic ailments, physical defects, bad eyesight, and growth abnormalities as the well-adjusted probationers. This finding conflicts with that of Glueck and Glueck (1950), but they used a sample of institutionalized delinquents, who tend to be judicially selected for robustness. The maladjusted among the nondelinquent controls showed the same excess of physical illhealth and defect. The relationship between disturbed behavior and chronic health conditions seems therefore to have a high degree of generality. It was evidently not due to a common factor of socioeconomic disadvantage, because it was equally strong among the probationers coming from homes of adequate standard. There seems to be no direct causeand-effect relationship between behavior disturbance and the chronic health conditions. Journal of Learning Disabilities
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148 Nevertheless, some powerful constitutional factor must be responsible for the association since it was many times closer when two distinct physical deficits were present (Stott 1966a). In a subsequent study of truants and controls, the relationship between behavior disturbance and chronic health problems was confirmed, and found to be even closer among girls, although the incidence of all deficits among them was much less than among the boys (Stott 1966a). In the course of a survey designed for the revision of the BSAG and the establishment of North American norms, the relationship between behavior disturbance and health problems was found among children of all social classes, and was indeed somewhat stronger among those of the highest of the four social-class groups. It became progressively stronger, among both boys and girls, and for both overreacting and underreacting maladjustment, as the number of distinct physical deficits increased to four to five per child (Stott, Marston, & Neill 1975). Thus, there seems to be empirical evidence for a law of multiple impairment, to the effect that any one handicapping condition renders others more probable in geometrical'progression. Everyday manifestations of this phenomenon are seen in multiple-impaired children, the practical difficulty of placing learning disabled children in mutually exclusive categories, and the growing doubts about learning disabilities as specific deficits (Senf & Grossman 1975). We have also to ask whether the frequent finding of perceptual and motor problems in poor readers represents a causal relationship or a multiple impairment of constitutional origin.
AIMS OF THE PRESENT STUDY This article reports an exploration of the relationships between motor impairment and the main types of behavior disturbance. The Test of Motor Impairment (Stott, Moyes, & Henderson 1972) used in the study was devised to measure mild motor handicaps which would be as
widespread as behavior disturbances among juveniles, while minimizing the influence of cultural, skeletal, cognitive, and emotional factors. Examination of the Oseretsky Test of Motor Ability showed that many of its items lacked objectivity. It also was too lengthy for practical use. A project for its revision following 15 criteria for item-acceptability (Stott 1966b) was supported by the British Spastics Society. The adoption of the modification devised by Gollnitz, which required no testing beyond the subject's age-level and gave a score for impairment rather than a quotient for ability, largely solved the problem of unwieldiness. The result, over five experimental editions and eight years of work, was the compilation of a virtually new test. Of its 45 items, only 16 were retained from the original Oseretsky test, and of these only two were used with the same age-level. Oseretsky's sixth category, synkinesis (unwilled associated movement), was abandoned because Fog and Fog (1962) had demonstrated its occurrence in the majority of normal children. A further major change was the compilation of an identical test for both sexes, which meant the abandonment of tasks which might favor one sex. Other items of the original Oseretsky were replaced because they could not be scored objectively, had too great a cultural component, aroused fears, required too great an effort of memory, or were physically dangerous. The test as published consists of five tasks for each age-level covering a range of motor performance which is relevant to the child's needs in everyday life. If the subject passes all five items, no further testing is required. If he fails one or more of the tasks at any age-level, two points are recorded (one point if failure is with one hand or foot only). Consequently, the higher the score, the greater the motor impairment. In the most recent normative study, scores between 6 and 7 indicated failure for 10 to 15$ of the sample. By analogy with the incidence of a range of other physical handicaps and habit disorders (Pringle, Butler, & Davie 1966), this score was taken as the criterion for definite motor
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35
149 impairment. A score of 0 to 2, which embraced 63.22 of the boys and 71.92 of the girls, was taken as indicating no significant impairment, or normal motor function.
THE ASSESSMENT AND TAXONOMY OF BEHAVIOR DISTURBANCE Behavior disturbance takes diverse forms, of an overreactive and underreactive character, and there are identifiable syndromes within this broad dichotomous classification (Stott 1971a, 1971b). The overwhelming likelihood is that these distinct forms have different origins. It would therefore be unfruitful to attempt to assess the relationship of motor handicap to behavior disturbance as a whole. The instrument chosen for the assessment of behavior disturbance was the Bristol Social Adjustment Guides (BSAG), a checklist of indications of good and poor adjustment. A study of 2,527 randomly selected school-aged students in an industrial city, smaller cities and towns, and rural areas of Ontario identified (1) 110 highly significant indicators of behavior disturbance as observed by teachers; (2) five core syndromes of behavior disturbance and various associated but nonsyndromic groupings within the classical overreactive-underreactive dichotomy. Norms were established for the main overreactive-underreactive scales and for the five core syndromes (Stott & Marston 1971, Stott 1971a, Stott, Marston, & Neill 1975). Five core syndromes of maladjustment were obtained from the above study: Unforthcomingness. The child fears new tasks or strange situations, and is timid with people while maintaining a need for affection. Withdrawal. Social unresponsiveness and apparent indifference to affection and human attachments, or a defensiveness against them. Depression. A lack of response to stimuli to which children normally respond, but without t h e a p p r e h e n s i v e n e s s c h a r a c t e r i s t i c of 36
unforthcomingness, or the unconcern or defensiveness of withdrawal. Inconsequence. A failure to restrain first impulses, and hence to monitor their consequences. Hostility. Provocative acts calculated to alienate people and to secure rejection, and/or a sullen avoidance of offers of friendship. On the BSAG, each item indicative of behavior disturbance confers a score of one, while the 'normal' items remain unscored. Hence, the higher the score, the more the type of behavior disturbance in question is in evidence. The items are strictly descriptions of behavior, including what in ethology are called sign releasers (means of communicating mood or attitude). Apart from the latter, the observer makes no interpretations, and no attempt is made to infer feeling-states such as of anxiety or inferiority.
DESCRIPTION OF THE SAMPLE The sample comprised the 1,940 school-aged students of the survey of social adjustment, who lived in the industrial city. This survey used a random sample consisting of those students aged 6 and 14 years who were born on the 15th or 16th day of any month, together with a small number past their 14th birthday who had missed promotion to the secondary stage of education. The schools they attended were divided into four socioeconomic groups on the basis of an assessment, made by school board officials, of the social desirability of the neighborhoods they served. To obtain a convenient subsample to which the motor test could be applied, the schools in each socioeconomic category were arranged in order of size, and testing was carried out, starting with the largest school, in a way that maintained the socioeconomic composition of the original sample. This composition in turn reflected that of the city as a whole except for those children who attended parochial schools. It also maintained the random character of the Journal of Learning Disabilities
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150 TABLE I. Motor impairment and type of maladjustment, Motor impairment scores
Unforthcomingness Withdrawal Depression Inconsequence Hostility
0-1 N=359
2-3 N=181
4-5 N=85
6+ N=88
Ratio: mean for 6+: mean for 0-1
1.20 0.37 0.31 1.49 0.62
1.48 0.43 0.49 1.77 0.98
1.73 0.44 0.64 1.66 0.60
1.39 0.56 0.57 3.26 0.98
1:1.16 1:1.51 1:1.84 1:2.19 1:1.58
Note: The figures in the body of the table are the mean scores for each type of maladjustment on the Bristol Social Adjustment Guides.
original sample. The above procedure was continued until 713 subjects (366 males and 347 females) had been tested. The scores obtained on the Test of Motor Impairment were related to those for the core syndromes of behavior disturbance.
RESULTS Table I gives the mean scores for each of the five core syndromes of behavior disturbance for various scores of motor impairment. As a quick means of assessing the degree of the relationship between these two variables, the mean coresyndrome scores of the motor-impaired subjects (a score of 6 or higher) are divided by those of the well-coordinated (a score of 0 or 1). In the resultant ratios, a ratio of one would indicate no relationship. The digits on the right side of the decimal, multiplied by 100, give the greater amount of behavior disturbance among the motor impaired as a percentage. It is seen that the mean behavior-disturbance scores show a fairly consistent tendency to rise with increasing motor impairment. Inconsequence stands out, with a ratio of 1:2.19, as the type of maladjustment most closely associated therewith. The relationship between motor impairment and the various types of behavior disturbance
can also be stated in terms of the proportions of each type of maladjusted child who is motor impaired, and the proportions of the motorimpaired children who are maladjusted. The criterion for maladjustment was the score received by approximately the most maladjusted 10$ within each core syndrome. This score corresponded to the highest score category in the BSAG as given in the manual (Stott 1971a). The lowest score category for each type of maladjustment was taken as indication of its absence. The criterion for motor impairment was a score of six or more, which was met by 12.9$ of the boys and 8.3$ of the girls, or 10.6$ for both sexes combined. Good motor coordination was defined as a score of 0 and 1 on the Test of Motor Impairment, which was obtained by 48.1$ of the boys and 58.4$ of the girls. The extent to which each type of behavior disturbance was associated with motor impairment is shown in Table II. It is seen that Unforthcomingness has no relationship to motor impairment, the nonsignificant chi-square value being derived from the somewhat smaller than chance overlap of the extreme categories of each variable. Withdrawal shows a small positive relationship which is, however, well below the level of significance. That of Depression is significant at a modest .05 level. Thus underreacting types of behavior disturbance as a whole are little associated with motor impairment.
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151 TABLE 11. The incidence of motor impairment associated with each core syndrome of maladjustment and of each maladjustment with motor impairment. Unforthcomingness Withdrawal Depression Inconsequence Hostility 9.7
15.8
19.5
31.3
18.6
Percent of sample not behavior disturbed but motor impaired
11.3
11.7
11.6
10.2
11.6
1
Ratio a of percentages
1:0.86
1:1.35
1:1.68
1:3.08
1:1.60
1 1 1
Percent of sample motor impaired and behavior disturbed
6.8
13.6
9.1
23.9
9.1
Percent of sample well-coordinated and behavior disturbed
7.8
9.2
3.6
5.8
5.0
1 1
Ratio b of percentages
1:0.87
1:1.48
1:2.51
1:4.09
1:1.81
7.19 ns
2.13 ns
9.23 .05
Percent of sample behavior disturbed and motor impaired
Chi-square
Of the two overreactive syndromes, Hostility has a positive but, owing to the small number of cases, a nonsignificant relationship to motor impairment. It should, however, be noted that the risks as calculated for motor impairment among the hostile, and hostility among the motor-impaired, were respectively 60$ and 80% above expectation. The relationship of Inconsequence to motor impairment was highly significant. More than 31% of Inconsequent children were motorimpaired compared with only 10% of the nonInconsequent; and 24% of the motor-impaired were Inconsequent compared with barely 6% of the nonmotor-impaired. Such overlaps are very large when it is considered that they are of the 10% most Inconsequent and the 11% motorimpaired within the sample as a whole. The statistically expected overlap would be 1.1%, so that those observed were 28 and 22 times respectively greater than chance. Ratio a shows that over three times as many Inconsequents as non-Inconsequents were motor-impaired; and ratio b shows that over four times as many of the 38
27.29 .001
4.13 ns
motor-impaired as the nonmotor-impaired were Inconsequent. The percentage incidence of each type of behavior disturbance among the motor-impaired and the well-coordinated respectively is depicted as bar graphs in Figure 1. The percentage incidence of motor impairment and good coordination respectively among each type of behavior-disturbed child is depicted in Figure 2.
DISCUSSION Of the various types of behavior disturbance, only Inconsequence was found to have a highly significant relationship to motor impairment. Such impulsivity would also often entail inadequate sensory input, that is, inattention; hence the poor performance of Inconsequent children on tests of visual perception and their being diagnosed as "perceptually handicapped." It similarly entails a lack of reflection about consequences; hence learning deficits in the form of poor conditioning and concept formation. Journal of Learning Disabilities
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152
Unforthcomingness •' i * •! •' i ! i ! •! •' i ! •!i:i:i;i:i;i;iii:»!i i • t ! i ! i ! • • t ? • I •! •
Motor Impaired
Withdrawal .lit,I.I.I.I.I.i,i.i.i.i,i.i.i.i.i.i.i.i,
I*ri i ' i ' I ' I r !I!I!I!I!I!I!I!»
Depression
Well Coordinated
i!i;i!i!i!i!i!i!ili!i!i!ili!i!i!ilililili Inconsequence
Hostility
15 20 Percentage of maladjusted students FIGURE 1. Incidence of maladjustment
among motor-impaired
The Inconsequent child typically has a tendency to guess in learning situations rather than take time to work out a solution. It must, however, be emphasized — lest the findings give rise to further overgeneralized diagnoses — that the relationship between motor impairment and Inconsequence is a complex one. Only a minority of the Inconsequent children were motor-impaired, and a still smaller minority of the motor-impaired were Inconsequent; moreover, 66$ of the motorimpaired group were in the lowest score category for Inconsequence, and 31$ of the Inconsequents were well coordinated. It is evident, then, that Inconsequence may have various primary causes, some of which may reflect cerebral dysfunction, while others may be cultural or environmental. The findings tend to confirm Keogh's (1971) conclusion that "there is solid evidence that the relationship between hyperactivity and cerebral dysfunction is in no sense one to o n e — All hyperactive children are not brain-damaged, and all children who are brain-damaged are not hyperactive/'
children.
There is an evident affinity between Inconsequence and those syndromes of behavior disturbance and learning disability which have been variously named the Strauss syndrome, minimal brain dysfunction, and hyperactivity (Strauss & Lehtinen 1947, Cruickshank, Bentzen, Ratzeburg, & Tannhauser 1961). These terms as they are currently used cover a heterogeneous and ill-defined array of behaviors. Nevertheless, the present findings are consistent with an explanation of the syndrome in terms of neural dysfunction. It is etiologically instructive that the type of behavior disturbance most closely associated with motor disability — that of a failure to control impulses — is the one which is most suggestive of brain dysfunction. In these circumstances it becomes diagnostically advisable to seek further evidence in the form of motor or other intrinsic handicaps, as distinct from hyperactivity or impulsivity which may arise from the lifestyle of the child and his social environment (Eells 1951, Schwebel 1966, Schwebel & Bernstein 1970). Even if such are observed, which would confer a strong suspicion
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39
153 > w o 0 o 0 o 0 o 0 o 0 o 0 o 0 o 0 o 0 o°o:
Unforthcomingness
Maladjusted
Withdrawal
Depression
Well-adjusted
Inconsequence
r
Hostility
o0o0o0o0o0o0o0o0o0o0o0o0o0o03 4 r» r\ r\ n r* r\ n
Q_0_Q_0_^^d
"T" 10
"T" 15
-J20
"T25
"T" 30
Percentage of motor-impaired students Figure 2. Incidence of motor impairment among maladjusted children. of neural dysfunction, the latter may not necessarily indicate brain damage. The dysfunction may be metabolic (Walker 1975) or a constitutional imbalance in the monitoring and sequencing of behavior. The above findings have practical implications for the assessment and education of the learning disabled child. Owing to the common observation that such children are clumsy and may also have reversal and other perceptual problems, it has sometimes been assumed that their motor impairment or poor perceptual performance is the cause of their learning disability. In this study it was seen that the type of behavior disturbance most closely associated with motor impairment was of a type calculated to produce behavioral handicaps to learning, in particular inattention and lack of reflectivity. In other words, the learning disability may be chiefly one of faulty learning style as an aspect of the behavior disturbance. If this is so, the motor impairment would be a concomitant rather than a cause of the learning disability. A further complication stems from the 40
tendency of primary handicaps to generate secondary impediments to learning in the form of adverse reactions to failure. Whether it be a physical handicap (e.g. deafness, poor vision, or clumsiness), or a temperamental handicap (e.g., impulsivity or excessive anxiety), or even a severely disadvantageous environment, the poor reinforcement in terms of success will result in some form of avoidance of the learning situation in all but the most highly motivated child. Examples of such avoidance strategies are task-evading distractibility, playing the role of a dull or retarded child, the use of charm to induce tolerance of the poor performance (Stott 1976). The self-consciousness produced by a speech defect may induce a retreat into pseudoretardation. That produced by motor disability may bring about a general reluctance to participate in informal activities and a generalized expectation of failure. In both cases, the manifest lack of confidence may be difficult to distinguish from a temperamental timidity. In this way, through the mediation of avoidance-reactions to failure, various primary Journal of Learning Disabilities
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154 causes of handicap may produce similar faults of learning style. These so dominate the picture, producing failure in mental and perceptual tests as well as in classroom learning, that it is often impossible to see beyond them to the primary handicap. This reactive behavioral component of manifest learning disability, however, opens up the possibility of at least partial remediation through appropriate conditioning programs (Stott 1971c). Indeed, the rate of response to such conditioning is a valuable diagnostic indicator, revealing the child's latent capability. We have to conceptualize all disabilities as relative and modifiable, and assessment by tests, however sophisticated, as registering only the extent of the handicap operative at the present time. Budoff (1974) has also argued that the rate of improvement in a mental test as a result of practice may be a more significant psychological variable than the ascertainment of a level of performance. The same applies to improvement in motor performance and behavioral adjustment. We badly need a program to train in self-confidence and self-control in motor activities. A final theoretical consideration arising from these findings is the interconnectedness of motor impairment with other handicaps, among which are behavior disturbances of a presumed constitutional or neurological origin. This means that we are unlikely to be able to identify single causes of learning disabilities or to establish clean categories of handicap. ABOUT THE
AUTHOR
Denis H. Stott was a professor of psychology and founding director of the Center for Educational Disabilities at the University of Guelph in Ontario until his retirement two years ago. With a degree from the University of London, he is the author of several books on delinquency, behavior disturbance, and learning difficulties. Requests for reprints should be sent to 30 Colborn St., Guelph, Ontario NIG 2M5.
REFERENCES Budoff, M.: Measuring learning potential: An alternative to the traditional intelligence test. In G.R. Gredler (Ed.): Ethical and Legal Factors in the Practice of School Volume
11, Number
3, March
Psychology. Harrisburg, Pa.: State Department of Education, 1974. Cruickshank, W.M., Bentzen, F.A., Ratzeburg, F.H., and Tannhauser, M.T.: A Teaching Method for Braininjured and Hyperactive Children: A Demonstration Pilot Study. Syracuse, N.Y.: Syracuse University Press, 1961. Eells, K.: Intelligence and Cultural Differences. Chicago: University of Chicago Press, 1951. Fog, E., and Fog, M.: Cerebral inhibition examined by associated movements. In M. Bax and R. MacKeith (Eds.): Minimal Brain Dysfunction (Little Club Clinics in Developmental Medicine No. 10), London: National Spastics Society and Heinemann, 1962. Glueck, S., and Glueck, E.: Unraveling Juvenile Delinquency. New York: Commonwealth Fund, 1950. Keogh, B.K.: Hyperactivity and learning disorders: Review and speculation. Exceptional Children, 38, 101-109,1971. Pringle, M.L.K., Butler, N.R., and Davie, R.: 11,000 Seven Year Olds. London: Longmans, 1966. Schwebel, A.I.: Effects of impulsivity on performance of verbal tasks in middle- and lower-class children. American Journal of Orthopsychiatry, 36, 13-21,1966. Schwebel, A.I., and Bernstein, A.J.: The effects of impulsivity on the performance of lower-class children on four WISC subtests. American Journal of Orthopsychiatry, 40, 629-636,1970. Senf, G.M., and Grossman, R.P.: State initiative in learning disabilities: Illinois' Project Screen. Report III: Local and state opinion regarding the concept of learning disabilities. Journal of Learning Disabilities, 8, 587-596, 1975. Stott, D.H.: Evidence for a congenital factor in maladjustment and delinquency. American Journal of Psychiatry, 118, 781-794, 1962. Stott, D.H.: Studies of troublesome children. London: Tavistock Publishers, 1966.a Stott, D.H.: A general test of motor impairment for children. Developmental Medicine and Child Neurology, 8,523-531, 1966.b Stott, D.H.: The social adjustment of children: Manual to the Bristol Social Adjustment Guides (4th ed.). London: University of London Press, 197La Stott, D.H.: Classification of behavior disturbance among school-aged students: Principles, epidemiology and syndromes. Psychology in the Schools, 8 (3), 232-239, 197Lb Stott, D.H.: The Flying Start Leaming-to-learn Kits, Parts I and II. Baltimore: University Park Press, 1971.c Stott, D.H.: A behavioral approach to the assessment, prevention and remediation of learning disabilities. In R. Hermelin (Ed.): Proceedings of the International Conference on Special Education, Canterbury, England, 1976. Stott, D.H., Moyes, F.A., and Henderson, S.E.: Test of Motor Impairment. Guelph, Ont.: Brook Educational, 1972. Stott, D.H.: and Marston, N.C.: The Bristol Social Adjustment Guides. San Diego: EITS, 1971. Stott, D.H., Marston, N.C., and Neill, S.J.: Taxonomy of Behavior Disturbance. Guelph, Ont.: Brook Educational, 1975. Stauss, A.A., and Lehtinen, L.E.: Psychopathology and Education of the Brain Injured Child. New York: Grune ir Stratton, 1947. Walker, J.: Drugging the American child: We're too cavalier about hyperactivity. Journal of Learning Disabilities, 8, 354-358, 1975.
1978
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41
Association of Motor Impairment with Various Types of Behavior Disturbance
Denis H. Stott, PhD
Many models of learning disabilities stress a particular disability as the core from which school failure and associated interpersonal problems derive. The disability is sometimes considered to be neurologically based though socalled process-deficit models are similar in their single disorder focus. In this article, Stott produces evidence for a multiple impairment theory. The position suggests that any one handicapping condition makes the child more prone to problems in other areas — the probability of additional problems increases disproportionally with each succeeding disability. The notion has intuitive appeal and opens new avenues for research. — G.M.S. The incidence of behavior disturbance among school-aged pupils was surveyed to explore the relationship of motor impairment to the core syndromes of disturbed behavior as identified by the Bristol Social Adjustment Guides. No excess of motor impairment was observed with the underreactive types of maladjustment. Among the overreactive types, Inconsequence, the failure to monitor the consequences of actions, showed a strong concordance with motor impairment. The relation of this finding to the Strauss syndrome and its implications for assessment of learning disabled and behavior disturbed children are discussed.
I
n boys placed on probation, Stott (1962) found a consistent relationship between disturbed behavior and chronic health problems. Using the Bristol Social Adjustment Guides 34
(BSAG), he found that maladjusted probationers had on the average over twice the incidence of chronic ailments, physical defects, bad eyesight, and growth abnormalities as the well-adjusted probationers. This finding conflicts with that of Glueck and Glueck (1950), but they used a sample of institutionalized delinquents, who tend to be judicially selected for robustness. The maladjusted among the nondelinquent controls showed the same excess of physical illhealth and defect. The relationship between disturbed behavior and chronic health conditions seems therefore to have a high degree of generality. It was evidently not due to a common factor of socioeconomic disadvantage, because it was equally strong among the probationers coming from homes of adequate standard. There seems to be no direct causeand-effect relationship between behavior disturbance and the chronic health conditions. Journal of Learning Disabilities
Downloaded from ldx.sagepub.com at Bobst Library, New York University on May 12, 2015
148 Nevertheless, some powerful constitutional factor must be responsible for the association since it was many times closer when two distinct physical deficits were present (Stott 1966a). In a subsequent study of truants and controls, the relationship between behavior disturbance and chronic health problems was confirmed, and found to be even closer among girls, although the incidence of all deficits among them was much less than among the boys (Stott 1966a). In the course of a survey designed for the revision of the BSAG and the establishment of North American norms, the relationship between behavior disturbance and health problems was found among children of all social classes, and was indeed somewhat stronger among those of the highest of the four social-class groups. It became progressively stronger, among both boys and girls, and for both overreacting and underreacting maladjustment, as the number of distinct physical deficits increased to four to five per child (Stott, Marston, & Neill 1975). Thus, there seems to be empirical evidence for a law of multiple impairment, to the effect that any one handicapping condition renders others more probable in geometrical'progression. Everyday manifestations of this phenomenon are seen in multiple-impaired children, the practical difficulty of placing learning disabled children in mutually exclusive categories, and the growing doubts about learning disabilities as specific deficits (Senf & Grossman 1975). We have also to ask whether the frequent finding of perceptual and motor problems in poor readers represents a causal relationship or a multiple impairment of constitutional origin.
AIMS OF THE PRESENT STUDY This article reports an exploration of the relationships between motor impairment and the main types of behavior disturbance. The Test of Motor Impairment (Stott, Moyes, & Henderson 1972) used in the study was devised to measure mild motor handicaps which would be as
widespread as behavior disturbances among juveniles, while minimizing the influence of cultural, skeletal, cognitive, and emotional factors. Examination of the Oseretsky Test of Motor Ability showed that many of its items lacked objectivity. It also was too lengthy for practical use. A project for its revision following 15 criteria for item-acceptability (Stott 1966b) was supported by the British Spastics Society. The adoption of the modification devised by Gollnitz, which required no testing beyond the subject's age-level and gave a score for impairment rather than a quotient for ability, largely solved the problem of unwieldiness. The result, over five experimental editions and eight years of work, was the compilation of a virtually new test. Of its 45 items, only 16 were retained from the original Oseretsky test, and of these only two were used with the same age-level. Oseretsky's sixth category, synkinesis (unwilled associated movement), was abandoned because Fog and Fog (1962) had demonstrated its occurrence in the majority of normal children. A further major change was the compilation of an identical test for both sexes, which meant the abandonment of tasks which might favor one sex. Other items of the original Oseretsky were replaced because they could not be scored objectively, had too great a cultural component, aroused fears, required too great an effort of memory, or were physically dangerous. The test as published consists of five tasks for each age-level covering a range of motor performance which is relevant to the child's needs in everyday life. If the subject passes all five items, no further testing is required. If he fails one or more of the tasks at any age-level, two points are recorded (one point if failure is with one hand or foot only). Consequently, the higher the score, the greater the motor impairment. In the most recent normative study, scores between 6 and 7 indicated failure for 10 to 15$ of the sample. By analogy with the incidence of a range of other physical handicaps and habit disorders (Pringle, Butler, & Davie 1966), this score was taken as the criterion for definite motor
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35
149 impairment. A score of 0 to 2, which embraced 63.22 of the boys and 71.92 of the girls, was taken as indicating no significant impairment, or normal motor function.
THE ASSESSMENT AND TAXONOMY OF BEHAVIOR DISTURBANCE Behavior disturbance takes diverse forms, of an overreactive and underreactive character, and there are identifiable syndromes within this broad dichotomous classification (Stott 1971a, 1971b). The overwhelming likelihood is that these distinct forms have different origins. It would therefore be unfruitful to attempt to assess the relationship of motor handicap to behavior disturbance as a whole. The instrument chosen for the assessment of behavior disturbance was the Bristol Social Adjustment Guides (BSAG), a checklist of indications of good and poor adjustment. A study of 2,527 randomly selected school-aged students in an industrial city, smaller cities and towns, and rural areas of Ontario identified (1) 110 highly significant indicators of behavior disturbance as observed by teachers; (2) five core syndromes of behavior disturbance and various associated but nonsyndromic groupings within the classical overreactive-underreactive dichotomy. Norms were established for the main overreactive-underreactive scales and for the five core syndromes (Stott & Marston 1971, Stott 1971a, Stott, Marston, & Neill 1975). Five core syndromes of maladjustment were obtained from the above study: Unforthcomingness. The child fears new tasks or strange situations, and is timid with people while maintaining a need for affection. Withdrawal. Social unresponsiveness and apparent indifference to affection and human attachments, or a defensiveness against them. Depression. A lack of response to stimuli to which children normally respond, but without t h e a p p r e h e n s i v e n e s s c h a r a c t e r i s t i c of 36
unforthcomingness, or the unconcern or defensiveness of withdrawal. Inconsequence. A failure to restrain first impulses, and hence to monitor their consequences. Hostility. Provocative acts calculated to alienate people and to secure rejection, and/or a sullen avoidance of offers of friendship. On the BSAG, each item indicative of behavior disturbance confers a score of one, while the 'normal' items remain unscored. Hence, the higher the score, the more the type of behavior disturbance in question is in evidence. The items are strictly descriptions of behavior, including what in ethology are called sign releasers (means of communicating mood or attitude). Apart from the latter, the observer makes no interpretations, and no attempt is made to infer feeling-states such as of anxiety or inferiority.
DESCRIPTION OF THE SAMPLE The sample comprised the 1,940 school-aged students of the survey of social adjustment, who lived in the industrial city. This survey used a random sample consisting of those students aged 6 and 14 years who were born on the 15th or 16th day of any month, together with a small number past their 14th birthday who had missed promotion to the secondary stage of education. The schools they attended were divided into four socioeconomic groups on the basis of an assessment, made by school board officials, of the social desirability of the neighborhoods they served. To obtain a convenient subsample to which the motor test could be applied, the schools in each socioeconomic category were arranged in order of size, and testing was carried out, starting with the largest school, in a way that maintained the socioeconomic composition of the original sample. This composition in turn reflected that of the city as a whole except for those children who attended parochial schools. It also maintained the random character of the Journal of Learning Disabilities
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150 TABLE I. Motor impairment and type of maladjustment, Motor impairment scores
Unforthcomingness Withdrawal Depression Inconsequence Hostility
0-1 N=359
2-3 N=181
4-5 N=85
6+ N=88
Ratio: mean for 6+: mean for 0-1
1.20 0.37 0.31 1.49 0.62
1.48 0.43 0.49 1.77 0.98
1.73 0.44 0.64 1.66 0.60
1.39 0.56 0.57 3.26 0.98
1:1.16 1:1.51 1:1.84 1:2.19 1:1.58
Note: The figures in the body of the table are the mean scores for each type of maladjustment on the Bristol Social Adjustment Guides.
original sample. The above procedure was continued until 713 subjects (366 males and 347 females) had been tested. The scores obtained on the Test of Motor Impairment were related to those for the core syndromes of behavior disturbance.
RESULTS Table I gives the mean scores for each of the five core syndromes of behavior disturbance for various scores of motor impairment. As a quick means of assessing the degree of the relationship between these two variables, the mean coresyndrome scores of the motor-impaired subjects (a score of 6 or higher) are divided by those of the well-coordinated (a score of 0 or 1). In the resultant ratios, a ratio of one would indicate no relationship. The digits on the right side of the decimal, multiplied by 100, give the greater amount of behavior disturbance among the motor impaired as a percentage. It is seen that the mean behavior-disturbance scores show a fairly consistent tendency to rise with increasing motor impairment. Inconsequence stands out, with a ratio of 1:2.19, as the type of maladjustment most closely associated therewith. The relationship between motor impairment and the various types of behavior disturbance
can also be stated in terms of the proportions of each type of maladjusted child who is motor impaired, and the proportions of the motorimpaired children who are maladjusted. The criterion for maladjustment was the score received by approximately the most maladjusted 10$ within each core syndrome. This score corresponded to the highest score category in the BSAG as given in the manual (Stott 1971a). The lowest score category for each type of maladjustment was taken as indication of its absence. The criterion for motor impairment was a score of six or more, which was met by 12.9$ of the boys and 8.3$ of the girls, or 10.6$ for both sexes combined. Good motor coordination was defined as a score of 0 and 1 on the Test of Motor Impairment, which was obtained by 48.1$ of the boys and 58.4$ of the girls. The extent to which each type of behavior disturbance was associated with motor impairment is shown in Table II. It is seen that Unforthcomingness has no relationship to motor impairment, the nonsignificant chi-square value being derived from the somewhat smaller than chance overlap of the extreme categories of each variable. Withdrawal shows a small positive relationship which is, however, well below the level of significance. That of Depression is significant at a modest .05 level. Thus underreacting types of behavior disturbance as a whole are little associated with motor impairment.
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151 TABLE 11. The incidence of motor impairment associated with each core syndrome of maladjustment and of each maladjustment with motor impairment. Unforthcomingness Withdrawal Depression Inconsequence Hostility 9.7
15.8
19.5
31.3
18.6
Percent of sample not behavior disturbed but motor impaired
11.3
11.7
11.6
10.2
11.6
1
Ratio a of percentages
1:0.86
1:1.35
1:1.68
1:3.08
1:1.60
1 1 1
Percent of sample motor impaired and behavior disturbed
6.8
13.6
9.1
23.9
9.1
Percent of sample well-coordinated and behavior disturbed
7.8
9.2
3.6
5.8
5.0
1 1
Ratio b of percentages
1:0.87
1:1.48
1:2.51
1:4.09
1:1.81
7.19 ns
2.13 ns
9.23 .05
Percent of sample behavior disturbed and motor impaired
Chi-square
Of the two overreactive syndromes, Hostility has a positive but, owing to the small number of cases, a nonsignificant relationship to motor impairment. It should, however, be noted that the risks as calculated for motor impairment among the hostile, and hostility among the motor-impaired, were respectively 60$ and 80% above expectation. The relationship of Inconsequence to motor impairment was highly significant. More than 31% of Inconsequent children were motorimpaired compared with only 10% of the nonInconsequent; and 24% of the motor-impaired were Inconsequent compared with barely 6% of the nonmotor-impaired. Such overlaps are very large when it is considered that they are of the 10% most Inconsequent and the 11% motorimpaired within the sample as a whole. The statistically expected overlap would be 1.1%, so that those observed were 28 and 22 times respectively greater than chance. Ratio a shows that over three times as many Inconsequents as non-Inconsequents were motor-impaired; and ratio b shows that over four times as many of the 38
27.29 .001
4.13 ns
motor-impaired as the nonmotor-impaired were Inconsequent. The percentage incidence of each type of behavior disturbance among the motor-impaired and the well-coordinated respectively is depicted as bar graphs in Figure 1. The percentage incidence of motor impairment and good coordination respectively among each type of behavior-disturbed child is depicted in Figure 2.
DISCUSSION Of the various types of behavior disturbance, only Inconsequence was found to have a highly significant relationship to motor impairment. Such impulsivity would also often entail inadequate sensory input, that is, inattention; hence the poor performance of Inconsequent children on tests of visual perception and their being diagnosed as "perceptually handicapped." It similarly entails a lack of reflection about consequences; hence learning deficits in the form of poor conditioning and concept formation. Journal of Learning Disabilities
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152
Unforthcomingness •' i * •! •' i ! i ! •! •' i ! •!i:i:i;i:i;i;iii:»!i i • t ! i ! i ! • • t ? • I •! •
Motor Impaired
Withdrawal .lit,I.I.I.I.I.i,i.i.i.i,i.i.i.i.i.i.i.i,
I*ri i ' i ' I ' I r !I!I!I!I!I!I!I!»
Depression
Well Coordinated
i!i;i!i!i!i!i!i!ili!i!i!ili!i!i!ilililili Inconsequence
Hostility
15 20 Percentage of maladjusted students FIGURE 1. Incidence of maladjustment
among motor-impaired
The Inconsequent child typically has a tendency to guess in learning situations rather than take time to work out a solution. It must, however, be emphasized — lest the findings give rise to further overgeneralized diagnoses — that the relationship between motor impairment and Inconsequence is a complex one. Only a minority of the Inconsequent children were motor-impaired, and a still smaller minority of the motor-impaired were Inconsequent; moreover, 66$ of the motorimpaired group were in the lowest score category for Inconsequence, and 31$ of the Inconsequents were well coordinated. It is evident, then, that Inconsequence may have various primary causes, some of which may reflect cerebral dysfunction, while others may be cultural or environmental. The findings tend to confirm Keogh's (1971) conclusion that "there is solid evidence that the relationship between hyperactivity and cerebral dysfunction is in no sense one to o n e — All hyperactive children are not brain-damaged, and all children who are brain-damaged are not hyperactive/'
children.
There is an evident affinity between Inconsequence and those syndromes of behavior disturbance and learning disability which have been variously named the Strauss syndrome, minimal brain dysfunction, and hyperactivity (Strauss & Lehtinen 1947, Cruickshank, Bentzen, Ratzeburg, & Tannhauser 1961). These terms as they are currently used cover a heterogeneous and ill-defined array of behaviors. Nevertheless, the present findings are consistent with an explanation of the syndrome in terms of neural dysfunction. It is etiologically instructive that the type of behavior disturbance most closely associated with motor disability — that of a failure to control impulses — is the one which is most suggestive of brain dysfunction. In these circumstances it becomes diagnostically advisable to seek further evidence in the form of motor or other intrinsic handicaps, as distinct from hyperactivity or impulsivity which may arise from the lifestyle of the child and his social environment (Eells 1951, Schwebel 1966, Schwebel & Bernstein 1970). Even if such are observed, which would confer a strong suspicion
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153 > w o 0 o 0 o 0 o 0 o 0 o 0 o 0 o 0 o 0 o°o:
Unforthcomingness
Maladjusted
Withdrawal
Depression
Well-adjusted
Inconsequence
r
Hostility
o0o0o0o0o0o0o0o0o0o0o0o0o0o03 4 r» r\ r\ n r* r\ n
Q_0_Q_0_^^d
"T" 10
"T" 15
-J20
"T25
"T" 30
Percentage of motor-impaired students Figure 2. Incidence of motor impairment among maladjusted children. of neural dysfunction, the latter may not necessarily indicate brain damage. The dysfunction may be metabolic (Walker 1975) or a constitutional imbalance in the monitoring and sequencing of behavior. The above findings have practical implications for the assessment and education of the learning disabled child. Owing to the common observation that such children are clumsy and may also have reversal and other perceptual problems, it has sometimes been assumed that their motor impairment or poor perceptual performance is the cause of their learning disability. In this study it was seen that the type of behavior disturbance most closely associated with motor impairment was of a type calculated to produce behavioral handicaps to learning, in particular inattention and lack of reflectivity. In other words, the learning disability may be chiefly one of faulty learning style as an aspect of the behavior disturbance. If this is so, the motor impairment would be a concomitant rather than a cause of the learning disability. A further complication stems from the 40
tendency of primary handicaps to generate secondary impediments to learning in the form of adverse reactions to failure. Whether it be a physical handicap (e.g. deafness, poor vision, or clumsiness), or a temperamental handicap (e.g., impulsivity or excessive anxiety), or even a severely disadvantageous environment, the poor reinforcement in terms of success will result in some form of avoidance of the learning situation in all but the most highly motivated child. Examples of such avoidance strategies are task-evading distractibility, playing the role of a dull or retarded child, the use of charm to induce tolerance of the poor performance (Stott 1976). The self-consciousness produced by a speech defect may induce a retreat into pseudoretardation. That produced by motor disability may bring about a general reluctance to participate in informal activities and a generalized expectation of failure. In both cases, the manifest lack of confidence may be difficult to distinguish from a temperamental timidity. In this way, through the mediation of avoidance-reactions to failure, various primary Journal of Learning Disabilities
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154 causes of handicap may produce similar faults of learning style. These so dominate the picture, producing failure in mental and perceptual tests as well as in classroom learning, that it is often impossible to see beyond them to the primary handicap. This reactive behavioral component of manifest learning disability, however, opens up the possibility of at least partial remediation through appropriate conditioning programs (Stott 1971c). Indeed, the rate of response to such conditioning is a valuable diagnostic indicator, revealing the child's latent capability. We have to conceptualize all disabilities as relative and modifiable, and assessment by tests, however sophisticated, as registering only the extent of the handicap operative at the present time. Budoff (1974) has also argued that the rate of improvement in a mental test as a result of practice may be a more significant psychological variable than the ascertainment of a level of performance. The same applies to improvement in motor performance and behavioral adjustment. We badly need a program to train in self-confidence and self-control in motor activities. A final theoretical consideration arising from these findings is the interconnectedness of motor impairment with other handicaps, among which are behavior disturbances of a presumed constitutional or neurological origin. This means that we are unlikely to be able to identify single causes of learning disabilities or to establish clean categories of handicap. ABOUT THE
AUTHOR
Denis H. Stott was a professor of psychology and founding director of the Center for Educational Disabilities at the University of Guelph in Ontario until his retirement two years ago. With a degree from the University of London, he is the author of several books on delinquency, behavior disturbance, and learning difficulties. Requests for reprints should be sent to 30 Colborn St., Guelph, Ontario NIG 2M5.
REFERENCES Budoff, M.: Measuring learning potential: An alternative to the traditional intelligence test. In G.R. Gredler (Ed.): Ethical and Legal Factors in the Practice of School Volume
11, Number
3, March
Psychology. Harrisburg, Pa.: State Department of Education, 1974. Cruickshank, W.M., Bentzen, F.A., Ratzeburg, F.H., and Tannhauser, M.T.: A Teaching Method for Braininjured and Hyperactive Children: A Demonstration Pilot Study. Syracuse, N.Y.: Syracuse University Press, 1961. Eells, K.: Intelligence and Cultural Differences. Chicago: University of Chicago Press, 1951. Fog, E., and Fog, M.: Cerebral inhibition examined by associated movements. In M. Bax and R. MacKeith (Eds.): Minimal Brain Dysfunction (Little Club Clinics in Developmental Medicine No. 10), London: National Spastics Society and Heinemann, 1962. Glueck, S., and Glueck, E.: Unraveling Juvenile Delinquency. New York: Commonwealth Fund, 1950. Keogh, B.K.: Hyperactivity and learning disorders: Review and speculation. Exceptional Children, 38, 101-109,1971. Pringle, M.L.K., Butler, N.R., and Davie, R.: 11,000 Seven Year Olds. London: Longmans, 1966. Schwebel, A.I.: Effects of impulsivity on performance of verbal tasks in middle- and lower-class children. American Journal of Orthopsychiatry, 36, 13-21,1966. Schwebel, A.I., and Bernstein, A.J.: The effects of impulsivity on the performance of lower-class children on four WISC subtests. American Journal of Orthopsychiatry, 40, 629-636,1970. Senf, G.M., and Grossman, R.P.: State initiative in learning disabilities: Illinois' Project Screen. Report III: Local and state opinion regarding the concept of learning disabilities. Journal of Learning Disabilities, 8, 587-596, 1975. Stott, D.H.: Evidence for a congenital factor in maladjustment and delinquency. American Journal of Psychiatry, 118, 781-794, 1962. Stott, D.H.: Studies of troublesome children. London: Tavistock Publishers, 1966.a Stott, D.H.: A general test of motor impairment for children. Developmental Medicine and Child Neurology, 8,523-531, 1966.b Stott, D.H.: The social adjustment of children: Manual to the Bristol Social Adjustment Guides (4th ed.). London: University of London Press, 197La Stott, D.H.: Classification of behavior disturbance among school-aged students: Principles, epidemiology and syndromes. Psychology in the Schools, 8 (3), 232-239, 197Lb Stott, D.H.: The Flying Start Leaming-to-learn Kits, Parts I and II. Baltimore: University Park Press, 1971.c Stott, D.H.: A behavioral approach to the assessment, prevention and remediation of learning disabilities. In R. Hermelin (Ed.): Proceedings of the International Conference on Special Education, Canterbury, England, 1976. Stott, D.H., Moyes, F.A., and Henderson, S.E.: Test of Motor Impairment. Guelph, Ont.: Brook Educational, 1972. Stott, D.H.: and Marston, N.C.: The Bristol Social Adjustment Guides. San Diego: EITS, 1971. Stott, D.H., Marston, N.C., and Neill, S.J.: Taxonomy of Behavior Disturbance. Guelph, Ont.: Brook Educational, 1975. Stauss, A.A., and Lehtinen, L.E.: Psychopathology and Education of the Brain Injured Child. New York: Grune ir Stratton, 1947. Walker, J.: Drugging the American child: We're too cavalier about hyperactivity. Journal of Learning Disabilities, 8, 354-358, 1975.
1978
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