Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?

Human Movement Science xxx (2015) xxx–xxx

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Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders? Sara Rosenblum ⇑ The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

a r t i c l e

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Article history: Available online xxxx PsycINFO classification: 2330 Keywords: Motor ability Space Time Developmental coordination disorders Handwriting Organization

a b s t r a c t Background and aim: Children with Developmental Coordination Disorders (DCD) exhibit deficient daily performance concealed in their perception–action mechanism. The aim of this study was to analyze behavior organization of children with DCD, in varied tasks that require generating and monitoring mental representations related to space and time inputs/requirements, for achieving better insight about their perception–action mechanism. Method: Participants included 42 children aged 7–10, half of whom were defined with DCD and half were typically developing (TD). The children were matched for age, gender and school. They were evaluated using the Movement–ABC and performed three handwriting tasks on an electronic tablet that is part of a computerized system (ComPET – Computerized Penmanship Evaluation Tool). In addition, their teachers completed the Questionnaire for Assessing Students’ Organizational AbilitiesTeachers (QASOA-T) to assess the children’s daily organizational ability. Results: Significant group differences (DCD versus controls) were found for all handwriting kinematic measures across the three handwriting tasks and for the children’s organizational abilities. Motor ability predicted a considerable percentage of the variance of the kinematic handwriting measures (30–37%), as well as a high percentage of the variance of their organizational abilities (67%).

⇑ Address: Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel. Tel.: +972 4 8240474; fax: +972 4 8249753. E-mail address: [email protected] http://dx.doi.org/10.1016/j.humov.2015.03.014 0167-9457/Ó 2015 Elsevier B.V. All rights reserved.

Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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The coefficient of variance of the pen tilt added an additional 3% to the prediction of their organizational abilities. Conclusions: The results of this study exhibited deficient ability among children with DCD in organizing their behavior in varied real-world tasks requiring generation and monitoring representation related to space and time. The significance of the results to understanding the performance mechanism and implication to the clinical field are discussed. Ó 2015 Elsevier B.V. All rights reserved.

1. Introduction Developmental coordination disorder (DCD), labeled in the past as ‘clumsiness’, is one of the most common hidden disabilities affecting school-aged children. DCD is characterized by motor impairment that interferes with the child’s activities of daily living and academic achievements (Blank, SmitsEngelsman, Polotajko, & Wilson, 2012; Cairney, Hay, Faught, Flouris, & Klentrou, 2007; Wann, 2007). Prevalence ranges from 1.4% to 19% among school aged children, depending on the definition used and the methods applied in their evaluation (Kadesjo & Gillberg, 1999; Lingam, Hunt, Golding, Jongmans, & Emond, 2009). The diagnosis of children with DCD leans mainly on the characteristics of their actions such as dressing, feeding, self-care, playing and writing (May-Benson, Ingolia, & Koomar, 2002). Fuster’s perception–action theory indicates that actions are specified from abstract plans to concrete responses (Fuster, 2004). Among children with DCD there is evidence of disturbance in the cognitive control which allows selection of actions that are consistent with the child’s goals and context (Badre, 2008; Zwicker, Missiuna, Harris, & Boyd, 2010). Previous findings of deficiency in two main domains related to cognitive control of children with DCD served as the background for this study. The first is their deficient action representation (Wilson, Maruff, Ives, & Currie, 2001; Gabbard & Bobbio, 2011) and the second is their deficient executive control (e.g., Alloway & Archibald, 2008). Deficits were found among children with DCD in generating accurate visuospatial representations of intended actions, monitoring and utilizing them (Lingam et al., 2009; Meltzer, 2007; Wilson et al., 2001; Wilson et al., 2004). Action representation can be viewed as a component of a predictive system including a neural process that is simulated through motor imagery which is the dynamic behavior of the body in relation to the environment (Bourgeois & Coello, 2009; Choudhury, Charman, Bird, & Blakemore, 2007; Gabbard & Bobbio, 2011). Beside the supporting findings of the action representation hypothesis, several authors linked children’s with DCD performance features to their insufficient executive control (e.g. Alizadeh & Zahedipour, 2005; Alloway & Archibald, 2008). Executive control encompasses high-level cognitive functions such as setting and managing goals, planning, inhibition and dealing with diverse elements, shifting among cognitive and affective sets, organization, working memory and metacognition (Ylvisaker & Feeney, 2002). Organization of behavior is a manifestation of the perceptual-motor cycle as it requires obtaining, conceptualizing, representing and integration of various space and time dimensions (Blanche & Praham, 2001). Spatial and temporal measures may also reflect the action representation process as successful action is evaluated by them (Gorelick, Blank, Shechtman, Irani, & Basri, 2007). In light of the neuro-occupation theory (Lazzarini, 2004), detailed knowledge from actual daily activities’ performance may shed light on the neural process involved in representation and control of actions (Badre, 2008). This theory is in line with the call for use of standardized ecologically valid evaluation tools that encompass real-world activities which indeed reflect the individual’s daily function abilities (Burgess et al., 2006; Lawrence et al., 2004). Based on previous results of varied aspects of daily function among children and adults with DCD (e.g., Rosenblum, Aloni, & Josman, 2010; Rosenblum & Livneh-Zirinski, 2008), the purpose of the Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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current study is to detect organizational behavior of children with DCD in varied daily tasks requiring different levels of mental action representation related to the dynamic interplay of the body and the external world demands. In this context, and beyond body movements, three types of daily tasks that require representation of sequence of actions while considering space and time dimensions will be analyzed. The relationships between performance characteristics of these tasks will be examined to achieve better insight of their deficient daily function performance mechanism (Lingam et al., 2009). The first type of task, requires organization of body movements related to space and time to execute motor tasks, with or without a certain object (such as a ball or scissors). During academic, play and social participation with peers, children are required to perform diverse gross and fine motor tasks such as balancing, playing with a ball, drawing or cutting with scissors. Such tasks are incorporated in the Movement-ABC (M-ABC) test (Henderson & Sugden, 1992), which currently serves as a tool used to support the medical diagnosis of DCD while providing evidence of motor coordination deficits (e.g., Ruiz & Gutierrez, 2003; Van Waelvelde, Peersman, Lenoir, & Engelsman, 2007). The execution of body movements needed to perform motor tasks as expected in the M-ABC require idea consolidation (‘what to do’), motor planning (‘how to perform’) and the execution of an intended action or activity according to its spatial and temporal dimensions (Ayers, 1989). When executing a motor action such as catching a ball, children need to generate and monitor internal visuospatial representation while considering time. They encode how far their legs and then their hands should extend; the appropriate timing of the action sequence (the first leg, second leg, hands); the amount of time each limb should be activated; and the appropriate action sequence in time and space (Levine & Reed, 2001). Efficient organized motor performance is expressed within the M-ABC scores (Henderson & Sugden, 1992). In view of the interplay between body and external demands, performance of such motor tasks is at the simplest level. Tasks based on body movement for a pre-defined motor task require cortical activation focused specifically on motor performance absent of additional cognitive effort and without occurrence of any dramatic environmental changes. Handwriting is the second form of task that requires space and time organization in both the representation and execution phases. Handwriting requires organization of continuous hand movements in space and time while controlling a tool on a given page space, and investing cognitive resources while considering linguistic content (Bonny, 1992; Reisman, 1993). Thus, this task form is more demanding the previously described type. Handwriting is a complex human activity, considered to be an ‘‘overlearned’’ skill involving particularly rapid sequencing of movements in time which reflects the relationship between planning and product generation (Van Gemmert & Teulings, 2006). Visuospatial abilities are essential for internalization of each letter, including letter stroke length, sequence, line directions and amount of alignment/curvature. This is required to produce the letters in an automatic manner on the page space. Automatic letter production means no investment of cognitive resources is required for the composition of the text’s content during the writing process itself (Berninger & Swanson, 1994; Medwell & Wray, 2007). Efficient performance is reflected in the written product legibility and amount of time required to produce the written text (Rosenblum, Weiss, & Parush, 2003). In this study, the handwriting performance characteristics of children with DCD and typical controls were evaluated using the Computerized Penmanship Evaluation Tool (ComPET) (Rosenblum, Parush, & Weiss, 2003), which supplies objective kinematic spatial and temporal measures of the handwriting process. Although significant differences were previously found for temporal measures between children with DCD and controls (Chang & Yu, 2010; Rosenblum & Livneh-Zirinski, 2008) the relationships between performance of varied handwriting and other motor and daily tasks have not yet been analyzed. In line with the desire for better insight of behavioral organization which requires mental representation related to space and time, the purpose of the current study was to discover whether the performance of children with DCD will be differ from that of controls in certain computerized measures, in three kinds of handwriting tasks (Alphabet sequence, numbers writing and paragraph copying). Furthermore, the relationships between specific handwriting performance measures and M-ABC scores (manual dexterity, ball skills, static and dynamic balance) were analyzed to achieve better insight of the perception–action mechanism that lies behind their performance. Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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The third issue observed in the current study relates to these children’s organization ability in daily function. Zentall and his colleagues (Zentall, Harper, & Stormont-Spurgin, 1993) defined organizational ability as the ability to plan how to execute an activity, within a limited amount of time, and place objects where they can be easily found (Zentall et al., 1993). Organization is a fundamental ability of executive functions (EF), which is essential to successful activity and participation in everyday life (Godefroy, 2003; Godefroy et al., 2004; Josman & Rosenblum, 2011). Thus, the ability to analyze, recode and represent spatial and temporal features is required for organization in daily tasks and routines and this is complex as both body location and environment’s demands found in dynamic change. Furthermore, many details and relationships between details need to be taken into account. For example, children must recode their daily morning action sequence in space and time from the moment they get up in the morning until they leave home for school. They need to represent the required sequence of actions at each point in time in relation to varied spaces (e.g., bedroom, kitchen) and accessories (clothes, schoolbag, notebooks, food). At school, these children require similar organizational competency that is dependent on the ability of action representations, such as arriving at class on time, finding the equipment they need for each school activity and taking out the appropriate notebooks. This recoding and temporal and spatial representation features process significantly influences the child’s ability to complete tasks in an effective manner. Therefore, daily functions are affected from the point of their initiation at the correct time and place, the ability to perform necessary activities at the appropriate speed in order to complete the activity in time and avoid interfering with the activity’s progress with undesirable behavior disturbances (Zentall et al., 1993). Daily organization typically occurs among children with maturation (Ayers, 1989; Blanche & Praham, 2001; Frith, Blakemore, & Wolpert, 2000; Wolpert, 1997). Deficits in organizational ability at school may possibly be related to the failure to accomplish academic requirements (Gambill, Moss, & Vescogni, 2008; Rosenblum et al., 2010). Therefore, in order to capture the perception–action mechanism’s manifestation standing behind daily function among children with DCD, the current study is focused on three types of real-world daily activities which require behavioral organization while representing space and considering time. Performance features of motor, handwriting, and daily organization tasks among children with DCD will be described compared to typically developed (TD) controls as well as to portray the relationships between the performance features of children in both groups. The research hypotheses state that significant differences will be found between children with DCD and typically developing children in the following measures: (1) Handwriting process measures of the three writing tasks (alphabet sequence, numbers and paragraph copying); and (2) Organizational ability as reflected through the teachers’ reports. Additionally, the research hypothesis relate to the predictability of some of their characteristic abilities, such as: (3) the motor performance abilities of children with DCD, as determined by the M-ABC, will predict their handwriting performance efficiency as manifested in the kinematic measures of the paragraph copy task; and (4) The participants’ motor task functioning (M-ABC) and their handwriting features will predict their organizational ability as reflected by their teachers’ reports. Finally, research hypothesis 5 states that organizational ability scores and kinematic handwriting measures will differentiate between the groups (DCD versus controls).

2. Methods 2.1. Participants Twenty-one children with DCD (13 boys) aged 7–10 years of age (study group), and 21 age- and gender-matched typically developing (TD) children (control group) participated in the study. No significant age differences were found between the two groups (DCD: M = 9 years and 9 month, SD = 1 month; controls: 9 years and 8 months’ SD = 1.3 month, t(40) = 0.086, p = .93). The children with DCD were recruited from schools and clinical centers based on educators’ or clinicians’ reports about motor coordination problems interfering with daily performance and handwriting deficiencies (based on the DSM-IV criteria for DCD (APA, 2000). The children’s DCD status was verified by testing Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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with the M-ABC (Henderson & Sugden, 1992). Children who scored below the 15th percentile for their age on the M-ABC were included in the DCD group. The control group was recruited from the same local schools and clinical centers as the DCD group. The 21 controls had no symptoms of DCD, as indicated by the children’s parents and teachers and by their M-ABC scores (Henderson & Sugden, 1992). Table 1 illustrates details of the M-ABC and scores of both groups. Children with known neurotic/emotional disorders, autistic disorders, physical disabilities or neurological diseases were excluded from the study. All subjects were native Hebrew speakers, attended regular schools which means IQ is of normal range, and reported no hearing or vision deficits. 2.2. Instruments 2.2.1. Movement assessment battery for children (M-ABC) (Henderson & Sugden, 1992) The M-ABC was developed as a clinical and research tool that provides an indication of motor functioning through fine and gross motor tasks for children aged 4–12 years. There are four age-related item sets which measure manual dexterity, ball skills, static balance, and dynamic balance. Each set consists of eight items and scores range from 0 to 5 on each item, resulting in a total score of 0–40 per set, appropriate to each age group. The total scores can be transformed to percentile scores. The M-ABC has acceptable validity and reliability (Henderson & Sugden, 1992) and has been previously validated among children in Israel (Engel-Yeger, Rosenblum, & Josman, 2010). 2.2.2. Computerized Penmanship Evaluation Tool (ComPET, previously referred to as POET) (Rosenblum et al., 2003) In the current study, children were asked to write their name and surname, the alphabet sequence from memory and to copy a paragraph as they usually write. The tasks were performed on an A4-sized lined sheet of paper affixed to the surface of a WACOM Intuos II x-y digitizing tablet (404  306  10 mm), using a wireless electronic pen with a pressure-sensitive tip (Model GP-110). This pen is similar in size and weight to regular pens commonly used by children and therefore does not require a change in grip that might affect their writing performance (see Fig. 1). Displacement, pressure and pen tip angle are sampled at 100 Hz via a laptop computer. The primary outcome measures are comprised of temporal, spatial and pressure measures for each writing stroke, as well as performance over the entire task. Further data about the pen azimuth and tilt is also supplied by the system. Based on previous analysis and the literature (Lacquaniti, Ferringo, Pedotti, Soechting, & Terzuolo, 1987; Rosenblum & Livneh-Zirinski, 2008; Rosenblum & Regev, 2013; Rosenblum et al., 2003), the following measures that reflect handwriting proficiency were analyzed for each of the three tasks: (1) Mean pen stroke duration. (2) Pen tilt coefficient of variance, pen tilt is measured at 0–90° (Fig. 2). Coefficient of variance (CV) is the ratio of the standard deviation to the mean and is a normalized measure of dispersion of a probability distribution or frequency distribution. Thus, the pen tilt CV reflects the amount of regularity of pen movements in space while writing.

Table 1 Means and standard deviations of M-ABC scores in each group (DCD versus controls).

Mean Mean Mean Mean Notes.

⁄⁄⁄

manual dexterity of ball skills of balance score of total MABC score

DCD (n = 21) M (SD)

TD (n = 21) M (SD)

F(1.40)/t

g2

2.62 2.17 1.46 2.07

1.08 (1.22) .38 (.48) .32 (.43) .62 (.57)

F = 16.46⁄⁄⁄ F = 35.16⁄⁄⁄ F = 19.85⁄⁄⁄ t(40) = 6.87⁄⁄⁄

.29 .47 .33

(1.24) (1.30) (1.08) (.78)

p 6 .001.

Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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Fig. 1. The Hebrew alphabet sequence (22 letters written from right to left).

Fig. 2. Pen tilt.

(3) Number of peak velocity’s per stroke – a measure for handwriting movement regularity, with the assumption being that the more peaks in one stroke, the less regular the movement will be (Caliguri & Mohammed, 2012; Marquardt, Gentz, & Mai, 1996; Mavrogiorgou et al., 2001). This measure reflects the time–space regularity while writing (as path/time = velocity). The present study focused on Hebrew writing. As demonstrated in Fig. 1, some of the Hebrew letters are constructed of two separate, unconnected components or strokes. For example, the first letter ) and the fifth letter ( ), (underlined) are each formed by two separate components. ( To enable comparison of study results in Hebrew writing with those of other languages, the measures for the written strokes are obtained for the entire writing task performance and are not based on single letters.

2.2.3. Questionnaire for assessing students’ organizational abilities-teachers (QASOA-T; Lifshitz & Josman, 2006) The QASOA-T includes 22 statements describing the child’s organizational abilities as reflected in the school environment (e.g., ‘‘The child manages to allocate work time efficiently during the lesson’’). Factor analysis of the questionnaire revealed three distinct factors: academic task performance (8 items) space and time management (10 items) and equipment organization (4 items) with a high level of internal validity for each factor (Cronbach’s alpha ranging from .87 to .96) (Lifshitz & Josman, 2006). The QASOA-T is scored on a 4-point Likert-type scale (0, always; 1, usually; 2, not often; 3, never). A higher score indicates a more severe level of organizational difficulties. The total score ranges from 0 (no difficulty) to 66 (maximum difficulty). The psychometric properties of the questionnaire among 82 school aged children were previously described (Lifshitz & Josman, 2006), with a mean score of 8.01 and a standard deviation of 9.7. Cronbach’s alpha used to establish internal consistency yielded a = .93 (n = 82). A cut off score of 18 confirms the diagnosis of disorganization (Lifshitz & Josman, 2006; Lifshitz, Josman, & Tirosh, 2012). In the current study the internal reliability based on Cronbach’s alpha was found to be a = .96 (n = 42). Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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2.3. Procedure The study was carried out with the permission of the Ethics Institutional Review Board at the University of Haifa and the Israeli Ministry of Education. A preliminary screening of the school children was conducted with the assistance of the school counselor to identify the children with DCD. Letters were sent to the parents, as well as a consent form for their child’s participation in the study. After receiving the signed consent form, the leading researcher administered the M-ABC test to confirm the DCD diagnosis. Following identification of 21 children who exhibited DCD diagnostic criteria and 21 matched controls, their parents were requested to complete the demographic questionnaire. At the same time, their teachers completed the QASOA-T. The handwriting evaluation was administered to all the children under similar conditions – in a quiet room in their school or in the clinic, under environmental conditions similar to those that the child is accustomed to. Each participant was tested individually during the morning hours. 2.4. Data analysis Descriptive statistics (means, standard deviations, percentages) were used to describe the study participants and main variables, and the internal reliability of the three QASOA-T subscales was analyzed using Cronbach’s alpha. As a result of the children’s age range (7–10), a preliminary correlation analysis was conducted between age and the M-ABC scores, handwriting measures and the QASOA-T score to determine whether age should be considered a covariate. Multivariate analysis of variance (MANOVA) was conducted with respect to the scores of each of the three subscales (manual dexterity, ball and balance) and a t-test was used to compare between the final M-ABC scores of the DCD and the control groups. Additionally, MANOVA was applied for each of the three ComPET handwriting performance measures (pen stroke duration, pen tilt coefficient of variation and number of peak velocities) across the three handwriting tasks (alphabet, paragraph copying and numbers writing) to compare between the study groups with respect to this area of function. In this analysis, age was treated as a covariate. Univariate ANOVA analyses were used to determine the source of the group differences. Moreover, three hierarchical regression analyses were conducted to determine whether the M-ABC score predicts handwriting performance efficiency as reflected through the kinematic measures of the paragraph copy task, while controlling for participant age. Next, a stepwise regression analysis was conducted to determine whether, when controlling for age, the M-ABC scores and the kinematic handwriting process measures predict the child’s organizational ability as reported by parents and teachers. Finally, discriminant analysis was conducted to determine whether the paragraph copying measures and the QASOA-T score may predict group membership (DCD versus controls). 3. Results Preliminary correlational analysis performed between the major study variables (i.e., age, M-ABC scores, handwriting measures, QASOA/P/T scores) indicted no significant correlations between age and M-ABC scores, pen tilt or QASOA-T score. In contrast, significant correlations were found between age and pen stroke duration (range: r .51 to .53 p < .01) and the number of velocity peaks per stroke (r range = .36–.55, p < .01). Hence the age variable was included as a covariate in the analyses related to these measures, as will be described further. As expected, the MANOVA analyses testing for group differences (DCD vs. controls) across the three subscales of the M-ABC (e.g., fine motor, ball skills and balance), yielded significant differences between the groups (F(3,38) = 17.10; p < .0001 g2 = .57). To examine in which of the three subscales group differences would be found, the data were subjected to a series of one-way MANOVAs. The results indicated significant differences between the groups in each of the three M-ABC subscales (see Table 1). Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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According to the first research hypothesis, between-group differences would be found in the computerized handwriting kinematic measures (i.e., mean pen stroke duration, pen tilt coefficient of variance and number of velocity peaks per stroke). This hypothesis was examined for each of the three handwriting process measures in all three handwriting tasks (e.g., alphabet sequence, paragraph copying and numbers writing) through a series of one-way MANOVAs. The age variable was included as covariate for the analysis of pen stroke duration and number of velocity peaks per stroke. To examine the source of significance for the task measures, the data were subjected to univariate ANOVAs and the results are presented in Table 2. Statistical analyses of all three handwriting measures yielded similar results. Specifically, results of the one-way MANOVA for the mean stroke duration, the pen tilt coefficient of variance as well as the mean number of velocity peaks per stroke yielded significant differences across all the three handwriting tasks (F(3,37) = 8.11, p < .001, Wilks’ Lambda = .60, ES-N2 = .39; F(3,38) = 5.34, Wilks’ Lambda = .70, p = .004, ES-N2 = .73; F(3,37) = 8.28, Wilks’ Lambda = .61, p < .001, ES-N2 = .38; respectively). As shown in Table 2, the subsequent univariate ANOVA analyses revealed that the source of the significance for each of the task measures was due to differences between the groups in all of the three handwriting tasks. This study also posited that the M-ABC total score can predict the handwriting kinematic measures of the paragraph copy task. This was examined through the use of three hierarchical regression analyses, for which the following results were revealed: The first hierarchical regression indicated that age accounted for 25% of the variance (F(1,40) = 14.55 p < 001 b = .51), whereas the total M-ABC score accounted for 32% of the variance (F(3,38) = 6.49 p = 001 b = 3.02) of the mean stroke duration while paragraph copying. Next, the second regression analysis indicated that age accounted for 1% of the variance (F(1,40) = 4.12, p = .049 b = .30), whereas the M-ABC score accounted for 31% of the of variance (F(3,38) = 10.67, p = .001 b = .52) of the pen tilt coefficient of variance while paragraph copying. Finally, the third regression analysis indicated that age accounted for 21% of the variance (F(1,40) = 12.11, p = .001 b = .48), whereas the total M-ABC score accounted for 37% of the of variance (F(2,39) = 30.167, p < .001 b = .62) of the number of peak velocities while paragraph copying. Thus, the results of these analysis indicated that the poorer the participants’ motor proficiency (higher scores on the M-ABC) the less proficient their handwriting was, as reflected in longer stroke durations, higher pen tilt coefficient of variance and greater number of velocity peaks. Poor organizational abilities in class are another difficulty limiting school achievement at this age. To determine group differences with respect to daily organizational abilities, this study employed the teacher’s scale of daily organization. As presented in Table 3, the results of the teachers’ reports on the QASOA-T, significant differences were found between the groups in their organizational abilities in class (t(38) = 4.31, p < .001). In fact, the questionnaire results indicated a considerably large gap in organizational abilities between the groups.

Table 2 A comparison of the kinematic handwriting process measures across the three handwriting tasks in both groups. M (SD)

DCD group (n = 21) M (SD)

Control group (n = 21) M (SD)

F

P

g2

Mean pen stroke duration (s) Alphabet task Paragraph copying Numbers writing

.93 (.46) .82 (.41) .56 (.43)

.52 (.16) .44 (.15) .43 (.11)

F(1,39) 15.95 25.02 12.22

<.001 <.001 .001

.29 .39 .24

Pen tilt coefficient of variance (0–90°) Alphabet task Paragraph copying Numbers writing

12.14 (4.02) 14.39 (3.71) 9.70 (4.45)

8.44 (2.49) 11.56 (2.92) 6.90 (1.87)

F(1,40) 12.83 7.53 7.05

.001 .009 .011

.24 .16 .15

Number of velocity peaks per stroke Alphabet task Paragraph copying Numbers writing

16.98 (7.19) 14.22 (6.81) 11.09 (3.87)

10.70 (3.50) 7.90 (3.13) 8.44 (2.69)

F(1,39) 15.71 22.21 10.50

<.001 <.001 .002

.28 .36 .21

Notes. ⁄p < .05;

⁄⁄

p < .001.

Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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S. Rosenblum / Human Movement Science xxx (2015) xxx–xxx Table 3 A comparison of organization ability during daily functioning in both groups as reported by teachers (QASOA-T).

Questionnaire for assessing the students organizational abilities for teacher (QASOA-T)

DCD group M (SD) n = 21

Control group M (SD) n = 21

t(38)

P

25.76 (10.49)

11.26 (10.77)

4.31

<.001

To examine the research hypothesis regarding the predictability of organizational ability in class (higher scores reported on the QASOA-T), based on the study group’s motor function deficit (high M-ABC scores) and lack of handwriting efficiency (kinematic measures of the paragraph copying task), a stepwise regression analysis was performed. Since correlation analysis conducted prior to the regression analysis indicated the presence of a high significant correlation between mean stroke duration and number of velocity peaks (r = .95, p < .001), only the mean stroke duration and pen tilt coefficient of variance of each of the three tasks as well as the QASOA-T mean score were inserted into the regression analysis. The results of stepwise regression, presented in Table 4, indicate that age did not contribute to the variance. However the M-ABC score accounted for 67% of the variance of the QASOA-T score (F(2,37) = 41.74, b = .83, p < .001), whereas the pen tilt coefficient of variance of the alphabet task alone – from among all the kinematic measures of all three handwriting tasks – contributed 3% to the prediction (F(3,36) = 31.84 b = .21, p < .04). All in all, the M-ABC score along with the pen tilt coefficient of variance for the alphabet task accounted for 70% of the variance of the QASOA-T final score, without any contribution from participant age. The final hypothesis examined in the current study suggested that QASOA-T mean score and handwriting kinematic measures could predict study group membership (DCD vs. controls). The study findings revealed one discriminant function that influenced the group classification of all participants (Wilks’ Lambda = .59, p < .001). The variable that made the greatest contribution to group membership was the QASOA-T mean score (loading = .85), followed by the mean stroke duration (loading .74), and lastly, the pen tilt coefficient of variance (loading .51). This one function explained the group membership of 83.3% of the participants overall, and specifically, 81% of the children with DCD and 86% of the controls. A Kappa value of .66 (p < .001) was calculated, demonstrating that this group classification did not occur by chance. 4. Discussion The aim of this study was to follow the performance features of children with DCD while performing varied tasks that require organization of behavior represented in space and while considering time, in order to achieve better insight of their perception–action mechanism. The fact that the motor performance of children with DCD was significantly different from that of controls as reflected by the M-ABC final score was to be expected. The results demonstrated that scores of the two study groups in each of the test’s sub-categories (i.e., manual dexterity, ball and

Table 4 Predicting organizational abilities in class based on the QASOA-T, the M-ABC scores and handwriting kinematic measures. Variable

Model 1 B

Age M-ABC score Pen tilt COV alphabet task R2 (Adj.rsq) F change in R2 Notes.

⁄⁄

p < .01;

⁄⁄⁄

Model 2 SE B

.073

.01 .48

.10

B

b .11

.16 1.32 .67 82⁄⁄⁄

Model 3 SE B .06 .14

b ⁄

.24 .83⁄⁄⁄

B

SE B

b

.13 1.1 .72 .70 4.39⁄

.06 .16 .34

.21⁄ .72⁄⁄⁄ .21⁄

p < .0001.

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S. Rosenblum / Human Movement Science xxx (2015) xxx–xxx

balance skills) differed significantly as well. In fact, the M-ABC scores reflect the deficient performance of children with DCD in motor tasks that require organization of behavior related to space and time while activating mainly body parts, at times together with certain objects. With respect to the handwriting kinematic measures, the findings indicated that children with DCD performed with significantly longer pen stroke duration times, higher pen tilt coefficient of variance (COV) and higher peak velocities compared to TD controls across all the three tasks (Alphabet sequence, numbers and paragraph copying). Accordingly, these three objective measures represent the handwriting execution dynamics among children with DCD, independent of the task type. Based on motor control theories, researchers have indicated that the more skilled and automatic the handwriting act, the less variability will be found in temporal (performance time), and spatial (length, height, width) measures, and greater consistency will be evident (Smits-Engelsman & Van Galen, 1997). Automatic movements such as these do not require investment of cognitive effort (Hiley, Zuevsky, & Yeadon, 2013; Wilson, Simpson, Van Emmerik, & Hamill, 2008). Thus, longer pen stroke duration, higher pen tilt COV, and higher peak velocities among children with DCD reflect inferior efficiency, consistency and automaticity of handwriting production. The finding of higher stroke duration and higher peak velocities is in line with previous findings about timing deficits among children with DCD (e.g., Piek, Dyck, Francis, & Conwell, 2007; Rosenblum & Regev, 2013). The pen tilt reflects the finger control of the writing instrument involving the thumb, index and the third finger. Hence, the higher pen tilt COV may be explained by fine motor deficits, and more specifically by previous findings of larger variability in the constant thumb-index finger pinching torque production among children with DCD (Oliveira, Shim, Loss, Petersen, & Clark, 2006; Smits-Engelsman, Wilson, Westenberg, & Duysens, 2003). Oliveira and his colleagues found that although children with DCD produce the same level of maximum finger force, they have poor control in manipulation tasks with a large number of kinetic redundancies (Oliveira et al., 2006). The pen tilt COV may possibly reflect this poor control. Further explanations to their deficient performance may be the deficient visual–spatial processing as well as deficient proprioceptive kinesthesis or tactile perception (Coleman, Piek, & Livesey, 2001; Smyth & Mason, 1997; Wilson & McKenzie, 1998; Zwicker et al., 2010). Maybe those deficiencies influence the child’s ability to decode, analyze and consider various spatial and temporal judgments (such as letter features, location, and relationships between letter parts) and thus related to their deficient action representation ability (Williams, Thomas, Maruff, & Wilson, 2008). Possibly, the less internalized letter/word features is the cause of the dis-automaticity. Support to this explanation may be indications in previous findings showing that children with dysgraphia wrote the same letter in five different formats all within one paragraph (Rosenblum, Dvorkin, & Weiss, 2006). Further studies are required to determine exactly how the above suggested possible underline mechanisms influence the actual performance, while using objective temporal, spatial and hand motion measure of the execution process. As mentioned before, defective handwriting represents a key diagnostic feature of DCD, hence supporting the relevance of these findings to our study. Moreover, the current study results are additionally supported by previous studies’ results that indicated that children with DCD, unlike other children their age, have not acquired the ability to automatically produce alphabet letters (Dixon, Kurzman, & Friesen, 1993; Rosenblum & Livneh-Zirinski, 2008, 2014). The innovative perspective presented in this study is the identification of three focused objective measures that are sensitive enough to document the children’s handwriting deficits. Future studies with larger samples may enable and lead to inclusion of such measures in the DSM definition criteria for diagnosis of DCD among school aged children. The results of the relationships between motor performance and handwriting kinematic measures may provide further support for a common underlying mechanism that can explain the characteristic of motor and handwriting performance among children with DCD. Results indicate that the M-ABC score indeed predicted more than 30% of the variance of each of the handwriting kinematic measures (mean pen stroke duration, pen tilt coefficient of variance and number of velocity peaks per stroke). Thus, it appears that the children’s overall motor proficiency level significantly contributes to the prediction of their handwriting consistency and automaticity. Functional, sequential, and continuous everyday tasks – including motor tasks such as ball catching, and letter or number writing involves Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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spatial analysis and timing ability thus require cortical activation (Schaal, Sternad, Osu, & Kawato, 2004; Zelanznik, Spencer, & Ivry, 2002). In addition to motor and handwriting deficits, significant differences were also found between the groups concerning the children’s organizational abilities in their daily classroom function. These results support previous reports that children with DCD have difficulties performing activities of daily living such as dressing, personal hygiene, cutting, eating and playing (Mandich, Polatajko, & Rodger, 2003; May-Benson et al., 2002; Missiuna, Moll, Law, King, & King, 2007; Rosenblum, 2006; Summers, Larkin, & Dewey, 2008). Furthermore, these results also find support from previous studies as regards to significant differences in EF such as organization and decision-making between children with DCD and typical controls (Alizadeh & Zahedipour, 2005). The novelty of the current results lies in the capacity of the QASOA-T to supply information about the child’s organizational abilities as required in class. Previous studies have shown that deficiency of these abilities may negatively influence the children’s academic achievements and even their self-esteem (Gambill et al., 2008; Rosenblum et al., 2010). Such organizational abilities need to be considered when planning evaluation and intervention methods aimed at improving these children’s performance abilities, particularly in light of the findings that these deficits continue to accompany the children over time as they grow up. In a study conducted among adults, Kirby and her colleagues found that 52% of students with DCD aged 16–25 showed EF weakness (Kirby, Sugden, Beveridge, & Edwards, 2008). Once the finding of significant differences in organizational abilities in class between the study groups was revealed, the next research hypothesis suggests that the M-ABC scores and the objective kinematic handwriting measures could predict the daily organizational ability of the two study groups. Results indicated that the M-ABC explained 67% of the variance, while the coefficient of variance of pen tilt adds an additional 3%. Together, these variables explained 70% of the organizational ability of these children in class. As previously stated, the coefficient of variance is a normalized measure of dispersion in a probability distribution, which may in fact reflect the variability of an individual’s performance related to pen movements. Therefore, the result could indicate that information regarding how children perform motor tasks, together with data regarding how they master pen movements in space and time, may enable us to predict their organizational abilities in daily class performance. In fact, both the M-ABC scores and the handwriting process measures reflect organizational abilities in space and time. The pen tilt measure indicates mastery over the instrument/pen and hand movements related to space while producing letters on paper. Hence, this finding supports a previous statement concerning the need for adequate organization in space and time in order to execute efficient body movements in daily functioning (Ayers, 1989; MacKay, 1985). Indeed, such results reinforce the statement that organization abilities which depend on spatial and temporal abilities begin at the body level and progress towards organizing objects, tasks and daily schedules (Ayers, 1989; Blanche & Praham, 2001). The pivot enhanced in the current study is the space and time input. In fact, these results indicate that not only is the motor performance of these children influenced by this potential deficit, but it may be related to their performance in other daily tasks. When considering the current results across all three different areas of performance (motor, handwriting, and organization) several explanations may be offered in light of previous findings. The variability of the DCD group’s movements in comparison to the controls was previously explained by internal temporal deficits that affect their ability to perform precise, synchronized movements at a reasonable rate (Ben-Pazi, Kukke, & Sanger, 2007; Geuze & Kalverboer, 1987, 1994; Johnston, Burns, Brauer, & Richardson, 2002; Mackenzie et al., 2008). Some researchers have linked this type of temporal problem with cerebellar function deficits (e.g., Bo, Bastian, Kagerer, Contreras-Vidal, & Clark, 2008; Lundy-Ekman, Ivry, Keele, & Woollacott, 1991) that may be related to under-activation of cerebellar–parietal and cerebellar–prefrontal networks and of brain regions associated with visual-spatial learning (Zwicker et al., 2010). Furthermore, visuo-spatial.and sensory processing deficits found among children with DCD at the level of receiving and encoding varied stimuli, may be related to their deficient organization ability related to space and time, which significantly correlate with their actual functioning (with their body, on paper and everywhere) (Ameratunga, Johnston, & Burns, 2004; Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014

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Coleman et al., 2001). An additional explanation for their deficient performance in all these three domains may be relate to their previously described deficient information processing abilities (Piek et al., 2004), executive functions, or more specifically, deficiencies in engaging ongoing attention focus, and working memory (e.g., Alloway & Archibald, 2008; Mandich, Buckolz, & Polatajko, 2003; Piek et al., 2004). It is also may be assumed that their deficient ability to decode, analyze and encode spatial and temporal features influences their action representation ability (Williams et al., 2008) as various spatial and temporal judgments are required for performing motor tasks, capturing letter features and remembering items at home or in class. In summary, children with DCD face more complex and demanding daily tasks in comparison to tasks required of them in laboratory studies. Following the neuro-occupation theory, actual daily performance is dynamic and may constitute a rich repository for understanding the underlying mechanism that explains the difficulties of children with DCD (Lazzarini, 2004). The current results describe the features of various areas of performance and may be explained by the difficulty children with DCD experience to encode process and execute performance considering space and time. However, still remains unclear ‘‘which came first, the chicken or the egg?’’. More studies are required to analyze whether poorer visual-spatial short term memory and difficulties in processing and storing temporal and spatial information (i.e., EF, particularly working memory deficits), as reflected through handwriting performance and daily functioning, may explain the deficient functionality among this population (Alloway, Rajendran, & Archibald, 2009). Nevertheless, results including the high percent of discrimination between groups, (83.3%) clearly emphasized the need to screen for both handwriting deficiency and daily function organization deficits among this population. Screening for handwriting deficiency is critical in light of previous findings concerning the importance of the letter production phase in proficient handwriting development, and in turn, for the development of the higher-order processes involved in text composition (Berninger & Swanson, 1994; Medwell & Wray, 2007), as well as its significance regarding the child’s overall learning potential (Christensen, 2009; Graham, Weintruab, & Berninger, 2001; Medwell & Wray, 2007). Early screening for both handwriting and organization abilities, while considering possible heterogeneity (Bo et al., 2008), may also prevent secondary emotional and social implications that can directly influence their self-image (Kaplan, Dewey, Crawford, & Wilson, 2001; Mandich et al., 2003; Segal, Mandich, Polatajko, & Cook, 2002; Skinner & Piek, 2001). Clearly, further studies are required for the consolidation of a theory that can explain the perception–action mechanism responsible for the performance-based difficulties of children with DCD and clarify the causes of the unique features that characterize their daily performance.

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Please cite this article in press as: Rosenblum, S. Do motor ability and handwriting kinematic measures predict organizational ability among children with Developmental Coordination Disorders?. Human Movement Science (2015), http://dx.doi.org/10.1016/j.humov.2015.03.014