CLUMSINESS IN CHILDREN-DO THEY GROW OUT OF IT? A 10-YEAR FOLLOW-UP STUDY Anna Losse Sheila E. Henderson David Elliman David Hall Elizabeth Knight Marian Jongmans
Some children have exceptional difficulty with tasks requiring motor co-ordination, such as writing, catching a ball or riding a bicycle. These children are not generally delayed, they have no classical neurological signs, and their difficulties cannot be linked to an identifiable neurological disease. Many terms have been used to describe their condition, including developmental agnosia and apraxia (Gubbay 1975), developmental dyspraxia (Denckla 1984) and, most recently, developmental co-ordination disorder (DSM-IIIR 1987), but it is most commonly known as the ‘clumsy child syndrome’. The problems of this group of children are of interest not only because they are directly distressing to the children themselves, but also because they are thought to be associated with a high incidence of learning difficulties, school failure and psychological problems. Over the last decade there have been a number of longitudinal descriptive studies on the early development of children with mild to moderate motor impairment (Silva and Ross 1980, Drillien and Drummond 1983, Hadders-Algra et al. 1986, Bax and Whitmore 1987). Most of these studies are somewhat limited, however, in that they were not specifically designed to document the natural history of motor difficulties in children. Rather, their main objectives were to investigate the consequences of particular perinatal
events, the effects of being exceptionally low birthweight and so on. Moreover, the majority of existing studies have not yet followed their subjects beyond puberty; only a few extend into the teenage years (e.g. Gillberg and Gillberg 1989). In spite of some recent evidence to the contrary (Gillberg and Gillberg 1989), it is still common to meet parents who have been told that the physical signs associated with ‘clumsiness’ disappear with maturation. It is also the case that parents are unable to obtain help for their child when progress in other aspects of schoolwork is considered satisfactory. This situation will not change until precise information on the long-term prognosis for ‘clumsiness’ is available and the effectiveness of remedial intervention is properly tested. About 10 years ago, two of the present authors conducted a detailed study of children selected by their teachers as having ‘poor co-ordination for their age’ (Henderson and Hall 1982). This group of children, labelled ‘clumsy’, was compared with matched controls in order to characterise the condition more precisely and to evaluate the different means by which it could be diagnosed. The aim of the present study was to re-examine these children, who are now teenagers, to determine their current motor, psychological and educational status.
W ICI ICI
55
i %
TABLE 1 ‘Clumsy’ and control groups in original study
2
8 4
-zr
F P
?
3
0
L4 0 c
2 ? 2
Measure* NDT TOMI Verbal IQ Performance IQ Good readers Poor readers
‘Clumsy’ (SO) Mean
Control Mean (SO)
12.16 15.12 102.7
3.12 0.84 112.9 109.2
(7.4) (4.25) (17.4) (17.2)
100.1 8 8
(2.4) (1.04) (12.1) (13.8) 14
2
P
0.001 0.001 NS NS 0.05
*NDT = neurodevelopmental test battery; TOMI =Test of Motor Impairment.
C
2
a .-
6
Method
.C
Original study In 1982 we described a sample of 32 children, 16 of whom were designated ‘clumsy’. 13 of this group were boys and three were girls. The control group was individually matched for age and gender and each pair of children was in the same class at school. All the children were in mainstream school and none had been referred for a medical or educational assessment. At approximately six years of age the children were given a neurodevelopmental examination, the Test of Motor Impairment, the short form of the WISC and the Schonell Reading Test. The differences between the two groups of children at that point are summarised in Table I.
v1
.-2
$
G
study During 1988 we traced all 32 of the subjects described in our 1982 paper, plus two described in footnote’, making a total of 34. They were now aged between 15 years 1 month and 17 years 4 months. We obtained complete data for 15 of the 17 ‘clumsy’ children and partial data for the other two-one girl had died of Hodgkin’s disease, but we were provided with extensive data from both her parents
FOllOW-Up
56
‘In our original study, one child in the control group was new to his school and unknown to his teacher. When tested by the paediatrician and psychologist, both found him to be extremely clumsy but at that time we did not consider it legitimate to move him into our target group because he had not been selected by his teacher. However, for the present study it seemed more sensible to include him in the ‘clumsy’ group. In 1982 we had collected data on a number of other children who were not included in the study. We were able to trace two of these to act as new controls.
and school; the other, a boy, refused to be tested but gave permission for his school records to be examined. One control subject refused to participate and another refused to be tested, but also gave permission for school records to be consulted. In the tables that follow, therefore, the number of subjects included will vary according to the type of data being reported. PROCEDURE
Each participant was assessed on five measures concerned with neurodevelopmental status, general motor competence, intelligence, self-concept and leisure interests. All tests were administered individually. For all but one test the clinical classification of each subject was unknown to the testers. The exception was the ‘Interests’ questionnaire, with its accompanying interview, which could not be done blind because the tester (E.K.) had assisted in tracing the children. In addition to the formal testing, as much information as possible was obtained from school records. There was considerable variation in the amount and type of this information available and we often supplemented it with parent interviews. NEURODEVELOPMENTAL TEST BATTERY WDT)
The neurodevelopmental examination used in our previous study has not been validated for use with teenagers, so we used the test battery and scoring system described by Stokman et al. (1986), for which extensive reliability and validity data are available. The items included assess astereognosis, dysgraphaesthesia,
dysdiadochokinesis, mirror movements, motor slowness and involuntary movements. The scoring procedure used for this test yields a standardised score for both the individual items and the battery as a whole. In each case the scores ranged between 0 and 1, with 0 indicating optimal performance. THE HENDERSON REVISION OF THE TEST OF MOTOR IMPAIRMENT
There is no functional test of motor competence that encompasses both gross and fine motor co-ordination and provides norms for young adults over the age of 15. The Test of Motor Impairment (TOMI) (Stott et al. 1984) was selected because it was used in the original study and has items known to be sensitive to differences between British children up to the age of 11. The eight test items designated for use with children 11 years and over were administered. These assess manual dexterity, ball skills, and static and dynamic balance. We were unsure whether the items for 1 1-year-olds would be sensitive to differences between teenagers as old as 17, so we retained both the raw scores and the scaled scores for analysis in this study. To produce the scaled scores the normative data for 11-year-olds was used. Each item was assigned a score of 0, 1 or 2. A score of 1 represents performance below the 15th percentile and a score of 2 below the fifth. The item scores are summed to give a total out of 16. The higher the score, the less able the child.
four domains of competence considered are cognitive, physical, social and general self-worth. Each of the four subscales contains seven items. A subject’s task on this test is to read a series of statements, such as ‘I am good at sport’ and decide how well it represents the perception they have of themselves on that dimension of behaviour. Each response is scored on a four-point scale. These are then summed and averaged to produce four subscale scores and an over-all score. In each instance high scores represent high self-regard. SCHOOL RECORDS
FOR
In this paper we report data from the last school report available for each child. More extensive information on school progress over the years will be reported elsewhere (e.g. Henderson el al. 1990). When analysing these reports we had two objectives: (1) to obtain as precise an index as possible of each subject’s academic performance in school and (2) to obtain a similar index of their competence in physical education (PE). Since achievement and effort were always commented on separately, we also rated them separately. In order to be able to compare teachers’ ratings of children attending different types of school and at different levels within a school, we designed rating scales for each dimension of performance. A five-point scale was used for academic achievement: 5 represented consistently good across all subjects, 4 good but variable, 3 average, 2 poor and variable, 1 consistently poor. The PE teachers’ reports were less detailed and a three-point scale was sufficient: 3 indicated good or above average, 2 average and 1 poor. In addition to rating each subject, teachers were required to provide a commentary on the student’s progress. From these data we noted every mention of a problem that could reasonably be related to lack of co-ordination or perceptuomotor competence and every instance of a behavioural problem.
This scale is designed to provide an estimate of an individual’s self-image in four separate domains of behaviour, plus an over-all estimate (Harter 1982). The
To investigate the question of whether the ‘clumsy’ children had developed different interests from their peers, we used an
WECHSLER CHILDREN
INTELLIGENCE
SCALE
FOR
As in our previous study, the short form of the WISC-R (Wechsler 1974) was used and the same four subtests were administered-the Similarities and Vocabulary from the Verbal section and the Block Design and Object Assembly from the Performance section. PERCEIVED CHILDREN
COMPETENCE
SCALE
m
INTEREST QUESTIONNAIRE AND INTERVIEW
57
i ‘CI
TABLE 11 ‘Clumsy’ and control groups at age 16 on four motor measures ~~
Measure
Tlumsy ’
Mean
Et
r T
~~
NDT TOM1 P E teachers’ reports Achievement Effort Classroom teachers’ reports: N with motor difficulties
(SO)
Control
Mean
(SD)
P
0.52 3.16
(0.26) (2.43)
0.21 0.13
(0.16) (0.35)
0.001
1.43 2.00
(0.51) (0.28)
2.56 2.88
(0.73) (0.72)
0.001 NS
14
0.001
0.005
0
C
e
9
2 0 .-C
TABLE I11 Performance on individual items of neurodevelopmental test
Item Astereognosis Dysgraphaest hesia Dvsdiadochokinesis M-inor movements Motor slowness Involuntary movements
‘Clumsy’
(SD)
Mean
(SO)
P
0-25
(0.29) (0.23) (0.25) (0.25) (0.22) (0.18)
0.14 0.12 0.19 0.26 0.26 0.05
(0.15) (0-20) (0.13) (0.26) (0.09) (0.14)
NS 0.001 0.05 NS 0.10 NS
0.41 0.35 0.46 0.40 0.10
adaptation of a questionnaire developed by Nias (1975). Three sections were chosen from the original questionnaire, covering school, leisure and sporting activities. For each activity listed on the questionnaire, subjects were asked to indicate whether they liked it, disliked it or had never done it, providing reasons where possible. From these data we calculated the percentage of activities they participated in, enjoyed and disliked in each section of the questionnaire. The interview material was not suitable for formal analysis, but was reserved for use in descriptive case studies.
Results Group comparisons between the ‘clumsy’ children and their controls The first question of interest in this study was whether the children previously designated ‘clumsy’ still differed from their controls in any way. MOTOR PERFORMANCE
58
Control
Mean
Table I1 shows that the teenagers who had been designated ‘clumsy’ in primary school differed substantially from the
control group on the neurodevelopmental battery, the TOMI and in the eyes of their teachers (p
Some children have exceptional difficulty with tasks requiring motor co-ordination, such as writing, catching a ball or riding a bicycle. These children are not generally delayed, they have no classical neurological signs, and their difficulties cannot be linked to an identifiable neurological disease. Many terms have been used to describe their condition, including developmental agnosia and apraxia (Gubbay 1975), developmental dyspraxia (Denckla 1984) and, most recently, developmental co-ordination disorder (DSM-IIIR 1987), but it is most commonly known as the ‘clumsy child syndrome’. The problems of this group of children are of interest not only because they are directly distressing to the children themselves, but also because they are thought to be associated with a high incidence of learning difficulties, school failure and psychological problems. Over the last decade there have been a number of longitudinal descriptive studies on the early development of children with mild to moderate motor impairment (Silva and Ross 1980, Drillien and Drummond 1983, Hadders-Algra et al. 1986, Bax and Whitmore 1987). Most of these studies are somewhat limited, however, in that they were not specifically designed to document the natural history of motor difficulties in children. Rather, their main objectives were to investigate the consequences of particular perinatal
events, the effects of being exceptionally low birthweight and so on. Moreover, the majority of existing studies have not yet followed their subjects beyond puberty; only a few extend into the teenage years (e.g. Gillberg and Gillberg 1989). In spite of some recent evidence to the contrary (Gillberg and Gillberg 1989), it is still common to meet parents who have been told that the physical signs associated with ‘clumsiness’ disappear with maturation. It is also the case that parents are unable to obtain help for their child when progress in other aspects of schoolwork is considered satisfactory. This situation will not change until precise information on the long-term prognosis for ‘clumsiness’ is available and the effectiveness of remedial intervention is properly tested. About 10 years ago, two of the present authors conducted a detailed study of children selected by their teachers as having ‘poor co-ordination for their age’ (Henderson and Hall 1982). This group of children, labelled ‘clumsy’, was compared with matched controls in order to characterise the condition more precisely and to evaluate the different means by which it could be diagnosed. The aim of the present study was to re-examine these children, who are now teenagers, to determine their current motor, psychological and educational status.
W ICI ICI
55
i %
TABLE 1 ‘Clumsy’ and control groups in original study
2
8 4
-zr
F P
?
3
0
L4 0 c
2 ? 2
Measure* NDT TOMI Verbal IQ Performance IQ Good readers Poor readers
‘Clumsy’ (SO) Mean
Control Mean (SO)
12.16 15.12 102.7
3.12 0.84 112.9 109.2
(7.4) (4.25) (17.4) (17.2)
100.1 8 8
(2.4) (1.04) (12.1) (13.8) 14
2
P
0.001 0.001 NS NS 0.05
*NDT = neurodevelopmental test battery; TOMI =Test of Motor Impairment.
C
2
a .-
6
Method
.C
Original study In 1982 we described a sample of 32 children, 16 of whom were designated ‘clumsy’. 13 of this group were boys and three were girls. The control group was individually matched for age and gender and each pair of children was in the same class at school. All the children were in mainstream school and none had been referred for a medical or educational assessment. At approximately six years of age the children were given a neurodevelopmental examination, the Test of Motor Impairment, the short form of the WISC and the Schonell Reading Test. The differences between the two groups of children at that point are summarised in Table I.
v1
.-2
$
G
study During 1988 we traced all 32 of the subjects described in our 1982 paper, plus two described in footnote’, making a total of 34. They were now aged between 15 years 1 month and 17 years 4 months. We obtained complete data for 15 of the 17 ‘clumsy’ children and partial data for the other two-one girl had died of Hodgkin’s disease, but we were provided with extensive data from both her parents
FOllOW-Up
56
‘In our original study, one child in the control group was new to his school and unknown to his teacher. When tested by the paediatrician and psychologist, both found him to be extremely clumsy but at that time we did not consider it legitimate to move him into our target group because he had not been selected by his teacher. However, for the present study it seemed more sensible to include him in the ‘clumsy’ group. In 1982 we had collected data on a number of other children who were not included in the study. We were able to trace two of these to act as new controls.
and school; the other, a boy, refused to be tested but gave permission for his school records to be examined. One control subject refused to participate and another refused to be tested, but also gave permission for school records to be consulted. In the tables that follow, therefore, the number of subjects included will vary according to the type of data being reported. PROCEDURE
Each participant was assessed on five measures concerned with neurodevelopmental status, general motor competence, intelligence, self-concept and leisure interests. All tests were administered individually. For all but one test the clinical classification of each subject was unknown to the testers. The exception was the ‘Interests’ questionnaire, with its accompanying interview, which could not be done blind because the tester (E.K.) had assisted in tracing the children. In addition to the formal testing, as much information as possible was obtained from school records. There was considerable variation in the amount and type of this information available and we often supplemented it with parent interviews. NEURODEVELOPMENTAL TEST BATTERY WDT)
The neurodevelopmental examination used in our previous study has not been validated for use with teenagers, so we used the test battery and scoring system described by Stokman et al. (1986), for which extensive reliability and validity data are available. The items included assess astereognosis, dysgraphaesthesia,
dysdiadochokinesis, mirror movements, motor slowness and involuntary movements. The scoring procedure used for this test yields a standardised score for both the individual items and the battery as a whole. In each case the scores ranged between 0 and 1, with 0 indicating optimal performance. THE HENDERSON REVISION OF THE TEST OF MOTOR IMPAIRMENT
There is no functional test of motor competence that encompasses both gross and fine motor co-ordination and provides norms for young adults over the age of 15. The Test of Motor Impairment (TOMI) (Stott et al. 1984) was selected because it was used in the original study and has items known to be sensitive to differences between British children up to the age of 11. The eight test items designated for use with children 11 years and over were administered. These assess manual dexterity, ball skills, and static and dynamic balance. We were unsure whether the items for 1 1-year-olds would be sensitive to differences between teenagers as old as 17, so we retained both the raw scores and the scaled scores for analysis in this study. To produce the scaled scores the normative data for 11-year-olds was used. Each item was assigned a score of 0, 1 or 2. A score of 1 represents performance below the 15th percentile and a score of 2 below the fifth. The item scores are summed to give a total out of 16. The higher the score, the less able the child.
four domains of competence considered are cognitive, physical, social and general self-worth. Each of the four subscales contains seven items. A subject’s task on this test is to read a series of statements, such as ‘I am good at sport’ and decide how well it represents the perception they have of themselves on that dimension of behaviour. Each response is scored on a four-point scale. These are then summed and averaged to produce four subscale scores and an over-all score. In each instance high scores represent high self-regard. SCHOOL RECORDS
FOR
In this paper we report data from the last school report available for each child. More extensive information on school progress over the years will be reported elsewhere (e.g. Henderson el al. 1990). When analysing these reports we had two objectives: (1) to obtain as precise an index as possible of each subject’s academic performance in school and (2) to obtain a similar index of their competence in physical education (PE). Since achievement and effort were always commented on separately, we also rated them separately. In order to be able to compare teachers’ ratings of children attending different types of school and at different levels within a school, we designed rating scales for each dimension of performance. A five-point scale was used for academic achievement: 5 represented consistently good across all subjects, 4 good but variable, 3 average, 2 poor and variable, 1 consistently poor. The PE teachers’ reports were less detailed and a three-point scale was sufficient: 3 indicated good or above average, 2 average and 1 poor. In addition to rating each subject, teachers were required to provide a commentary on the student’s progress. From these data we noted every mention of a problem that could reasonably be related to lack of co-ordination or perceptuomotor competence and every instance of a behavioural problem.
This scale is designed to provide an estimate of an individual’s self-image in four separate domains of behaviour, plus an over-all estimate (Harter 1982). The
To investigate the question of whether the ‘clumsy’ children had developed different interests from their peers, we used an
WECHSLER CHILDREN
INTELLIGENCE
SCALE
FOR
As in our previous study, the short form of the WISC-R (Wechsler 1974) was used and the same four subtests were administered-the Similarities and Vocabulary from the Verbal section and the Block Design and Object Assembly from the Performance section. PERCEIVED CHILDREN
COMPETENCE
SCALE
m
INTEREST QUESTIONNAIRE AND INTERVIEW
57
i ‘CI
TABLE 11 ‘Clumsy’ and control groups at age 16 on four motor measures ~~
Measure
Tlumsy ’
Mean
Et
r T
~~
NDT TOM1 P E teachers’ reports Achievement Effort Classroom teachers’ reports: N with motor difficulties
(SO)
Control
Mean
(SD)
P
0.52 3.16
(0.26) (2.43)
0.21 0.13
(0.16) (0.35)
0.001
1.43 2.00
(0.51) (0.28)
2.56 2.88
(0.73) (0.72)
0.001 NS
14
0.001
0.005
0
C
e
9
2 0 .-C
TABLE I11 Performance on individual items of neurodevelopmental test
Item Astereognosis Dysgraphaest hesia Dvsdiadochokinesis M-inor movements Motor slowness Involuntary movements
‘Clumsy’
(SD)
Mean
(SO)
P
0-25
(0.29) (0.23) (0.25) (0.25) (0.22) (0.18)
0.14 0.12 0.19 0.26 0.26 0.05
(0.15) (0-20) (0.13) (0.26) (0.09) (0.14)
NS 0.001 0.05 NS 0.10 NS
0.41 0.35 0.46 0.40 0.10
adaptation of a questionnaire developed by Nias (1975). Three sections were chosen from the original questionnaire, covering school, leisure and sporting activities. For each activity listed on the questionnaire, subjects were asked to indicate whether they liked it, disliked it or had never done it, providing reasons where possible. From these data we calculated the percentage of activities they participated in, enjoyed and disliked in each section of the questionnaire. The interview material was not suitable for formal analysis, but was reserved for use in descriptive case studies.
Results Group comparisons between the ‘clumsy’ children and their controls The first question of interest in this study was whether the children previously designated ‘clumsy’ still differed from their controls in any way. MOTOR PERFORMANCE
58
Control
Mean
Table I1 shows that the teenagers who had been designated ‘clumsy’ in primary school differed substantially from the
control group on the neurodevelopmental battery, the TOMI and in the eyes of their teachers (p
