Perceptual, Coding, Visuomotor and Spatial Difficulties and their Neurological Correlates: a...

Develop. Med. Child Neurol. 1965,7,543-548

Marjorie Walker

Perceptual, Coding, Visuomotor and Spatial Difficulties and their Neurological Correlates:

a Progress Note

Introduction CLINICAL impressions suggest that children with unusual learning problems are not a homogeneous group but show many different weaknesses. These are of varying kinds and severity, and include difficulties in the comprehension and/or usage of language not sufficiently severe or circumscribed to be designated aphasias; difficulties in memory, discrimination and gestalt recognition in the visual, auditory and kinaes- thetic spheres; difficulty in coding; and problems of visuo-spatial relationship and spatial orientation. Many cases show all these features to varying extents, while in others the difficulties appear to fall more strikingly in the auditorylcoding and visuo-spatial/motor areas.

Unfortunately, the evaluation of these different characteristics is largely subjec- tive; it is based on cumulative personal impressions within a particular theoretical framework, and will be biased by the population seen. Thus in evaluating those widely recognised specific weaknesses shown by children with learning difficulties, some observers will be lead to think in terms of syndromes and neurological

correlates and others in terms of extreme deviation from the norm, made more gross by a cumulative interaction with environ- mental influences. There is a need, therefore, for normative data against which assessment can be made, and for inter-test correlations on those characteristics which clinical experience suggests are significantly associated but which may have only apparent, not real, validity as syndromes.

The Main Study The main study, of which the pilot to

be described is a precursor, attempts to examine this wide range of functions in cross-sectional groups of children of primary school age and, within this matrix, to evaluate the findings in children with serious learning difficulties, particularly the relationship of any ‘clustering’ of difficulties to the inter-test correlations in the cross-sectional groups. It is hoped that the findings, taken in conjunction with neurological-developmental observations, and family, medical and developmental histories, will provide evidence on which the statistical and logical validity of the

Miss Walker is an educational psychologist to the Inner London Education Authority. The views expressed here are her own and do not necessarily represent those of the London County Council.

Address: Child Guidance Unit, Woodberry Down Health Centre, Green Lanes, London, N.4.

543

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1965, 7

clinically defined conditions of specific and accuracy the child drew a line through the centre of a number of beads scattered over dyslexia can be assessed. the page in poor alignment.

3. Visuo-Spatial Skill. (a) Copying free drawings, including simple angles. (b) Copying simple figures made by joining dots. This test was similar to the Frostig Spatial Relations Test (Frostig 1961), but was derived from an Army test.

4. Speed of Visual Discrimination for Symbols of Differing Orientation. This was a timed can- cellation test which, used in conjunction with a timed ‘making crosses’ test, gave a measure of ‘scanning time’. It was similar to the Deux Barrages of Zazzo (1960), but was derived

whose ages ranged from 6 years 11 months 5 . Serial Order. The child was asked to complete a series of short strings of beads by adding

to 9 years 4 months, provided the cross- more ‘in the same order’. sectional group. In addition to this main 6. Hidden Figures. The child was asked to ‘find‘

the toys which were lost in a matrix of con- fusing lines.

seven children who presented severe learn- 7. Visual Memory. This was a simplified version of the Benton Visual Retention Test (Benton

ing problems but who were, in his view, 1955). neither educationally subnormal nor mal- 8 . Percepiion of Directional Continuity. The child

was asked to ‘sort out’ tangled kite strings. adjusted’ Most Of the tests were 9. Auditory Analysis and Synthesis. The child was given to the children in groups, but certain asked to choose the picture which began with

the same sound as the given word, and the one which represented the unblended given sounds. additional tests, including various meas-

ures of neurological status, were given 10. Auditory Memory. (a) Memory for words of dissimilar sound, chosen from a series of un- like sounds. (b) Memory for words of similar individually. A rough measure of general

intellectual development was provided by sound, chosen from a series of pairs of pictures of similar sound-for example, church; cot, duck‘ would be chosen from Matrices and Vocabulary scores. The

special tests were designed primarily to ‘shirt, church; cot, sock; duck, cup.’ It was felt that some children might discriminate between words of slightly different sound but elucidate the suspected difficulties of

certain hypothesised clinical groups. These show lack of precision when recalling them. groups are critical to the design of the This might be related to a weak ‘fixing’ of the

sound by association with meaning, and a test main investigation, but since they are of of this kind might therefore be of value where only incidental importance for the pilot an aphasic type of difficulty was suspected.

11. Coding. This test involved the association of study they will not be discussed at this meaning with visual symbol, the rationale stage. A brief description of the tests being a suspected difficulty in symbolic repre-

sentation. It was presented as a linked series follows, but without full reference to their and consisted of: (a) A simple timed coding rationale. test in which key pictures were given with

their related symbols. Each symbol was a reduced representation of the picture and thus had a direct and meaningful visual association with it--e.g., a cross stood for a pair of scissors. (b) A timed ‘copying. the symbols’

These were all of a paper-and-pencil test which, used in conjunction with the simple coding’ test, yielded a ‘coding time’ (inevitably contaminated with visual scanning

1. Right-Left Discrimination. These followed the and recognition). (c) Related simple symbols pattern of the Benton protocol (Benton 1959). were now presented as composite symbols They were presented as a series of games: representing more general concepts under ‘mixed self-other’, for example, was a football which the original objects were subsumed- game where the child ‘kicked‘ the R/L ball for example, a square with a cross inside it over the goalie’s R/L shoulder. (B) stood for sewing (0 = reel of cotton;

2. Motor Control. (a) In an untimed test, scored X = scissors). There were six composite for accuracy only, the child followed the track symbols in all and the meaning of each made by a boy going down a hdl on a was demonstrated in turn and was clearly toboggan. (b) In a timed test scored for speed set out on the page with supporting pictures

The Pilot Study The pilot study was designed as a test

of the tests. It was of only limited value as a study of specific dyslexia, but the findings were felt to be of sufficient general interest to be reported at this stage.

Twenty-six primary school children, from Newsom (1955).

group, the head of the school put forward

The Special Group Tests

type :

544

MARJORIE WALKER

in three cases. Certain of the composite symbols had elements in common and, in the case of toys (@) and summer (@) were the same symbols in different orientations, though of different derivation (the circle and the triangle representing in the one case a ball and a top, and in the other the sun and a boat). More important than the perceptual confusions were the conceptual links between different pairs of composite symbols, for fxample the particularly abstract concepts of sky’ and ‘summer’ could only be distinguished

by calling up both concepts and ‘sorting out’ the associations: thus summer (@) was represented by boat (A) and sun (O), but might have been represented by kite (+) and sun (0); but kite and sun stood for sky (@), and in order to make the correct choice the alter- native had to be remembered, linked with a different concept, and then rejected. A confusion of such concepts might demonstrate a failure to make clear unambiguous linkages and might thus be of value in picking up children with aphasic difficulties. The test involved the selection of the correct composite symbol in response to the given word, at first with the help of the clues provided by the picture, and then without. Finally the child was asked to write the symbol for the given word.

12. Following Instructions of Increasing Verbal Difficulty and Confusion. The child was given a drawing of a circus scene and was asked to carry out a series of complex verbal instructions-for example, his attention was drawn to the see-saw with three dogs on it and he was asked to ‘put a cross on the dog in the middle and draw a tail on the one at the end’.

The Individual Tests

Warrington 1962). The criterion adopted was that on at least two of the three tests the child should make six out of eight correct responses.

8. Choreiform Movements. These were assessed on finger extension, as described by Prechtl and Stemmer (1962).

Treatment of the Results Performance on the finger gnosia,

associated movements, Oseretsky and Prechtl tests is used by some writers as evidence of neurological status. A so- called ‘neurological’ group was therefore formed on the basis of the following criteria: (a) ‘Failure’ on the finger gnosia test.

Among the younger children failure on this test was not necessarily an abnormal finding, but chronological age was nevertheless not taken into account.

(b) An arbitrarily chosen rank order of 20th or lower (in the cross-sectional group of 26) for associated movements, the ‘special learning difficulties’ group being given rank orders corresponding to those of children in the main group with the same raw scores. Roughly, therefore, a rank order of 20th or

1. 2.

3.

4. 5.

6.

7.

Speed of Articulation. lower in the cross-sectional group of Ideational Fluency: (a) words per minute; (b) 26 children represented 20 per cent of

this population, but since most of the food, toys, animals, each for 30 seconds. Copying Simple Rhythms. Twelve (unnamed) nursery rhymes were clapped and the child was ‘special learning difficulties’ children

fell at this level on most or all of the asked to copy these. Poor motor control, provided the basic rhythm was maintained, was not penalised. tests, the proportion of the total group Assessment of Laterality. was considerably more than this. Oseretsky Tests of Motor Development- Gollnitz Revision. These test six categories of Chronological age was again not taken motor ability and cover motor co-ordination, into account. speed, and the ability to make isolated movements without associated movements. For each (c) The six categories Of motor ability child a cumulative score was obtained for each tested by the Oseretsky were listed category. Associated Movements. These were observed on separately, the notional age for each (a) lifting a single finger; (6) lifting two fingers; being a cumulative score. One child

had a deficit of only one year in one (c) lifting two fingers, one on each hand simultaneously. The procedure followed was that outlined by Zazzo in Trois dpreuves de category, but a problem of inclusion

did not arise because she failed on the syncindsies (Zauo 1960). The final measures used was the sum total of all observed movements. finger gnosia test and had a rank

order of 26th for associated move- Finger Gnosia. This was assessed on the child’s performance on the Kinsbourne-Warrington Finger Tests 1, 2 and 4 (Kinsbourne and ments. The remaining 12 children, 10

545


546

boys and 2 girls, had deficits of two years or more on one or more of the subtests, with marked deficits, ranging up to five years, in 3 of the children.

(d) Choreiform movements, as described by Prechtl, were seen in 6 children, all boys, and each had already been in- cluded under categories (b) and (c).

The ‘neurological’ group chosen on the criteria described consisted of 16 out of the 33 children. All but one of the ‘special learning difficulties’ children were found to be in this group, as well as the 4 children from the cross-sectional group who were seriously retarded. Altogether there were 11 retarded children, all with serious spelling problems, and all but one were found in the group chosen on the so-called ‘neurological’ criteria.

Although the findings in the ‘neurological’ group were striking on cursory inspection, it seemed important to match these children for chronological age and Vocabulary, and for chronological age and Matrices Age, with children who did not fall into this category. (There are, of course, pitfalls. A child might, for example, be in the so-called ‘neurological’ group because of ‘failure’ on the finger gnosia test, a failure which might have been equivocal at that age level, while the control, who ‘passed’ the test, might have been very similar in terms of ‘neurological’ status. Another problem was finding good controls for such a large number of children. Three of the original ‘neurological’ group had to be discarded because there were no suitable controls, while one of the controls had to be used three times and another twice. No attempt could be made to match for sex.)

General Findings The findings showed that there was no

consistent association of perceptual, visuo- spatial or coding deficits with the finger gnosia, associated movements, Oseretsky

or Prechtl findings, nor with reading disability. There were, nevertheless, striking loadings of disability, the 4 children who ‘failed’ on all the ‘neurological’ tests having more marked and widespread deficits on the ‘special’ tests. Detailed medical histories were not available for these children, but 3 were small and of very poor physique, while the fourth, though looking healthy and robust, was slow in speaking, slow and clumsy in moving, and very poor indeed in all the areas measured. But although the perceptual, visuo-spatial and coding types of difficulty were severe and widespread in the children who ‘failed’ on all the ‘neurological’ tests, they tended to be patchy, though well-marked in the others.

The only conclusion that could be drawn was that the greater the ‘neurological’ loading (using the word ‘neurological’ without any necessary implication of disease), the greater was the likelihood of extensive perceptual, visuo-spatial and coding weaknesses. The marginal ‘neurological’ children had marginal disabilities on the perceptual, visuo-spatial and coding tests, but no child with a ‘neurological’ loading, however slight, was clear of perceptual/visuo-spatial/coding difficulties (using the arbitrary cut-off point of a rank order of 20th).

In so far as the Prechtl and Oseretsky tests are independently derived measures believed to be sensitive to minimal brain damage, the close correspondence of the findings, and the scatter of deficits in the less heavily loaded children, may point to some physiological-neurological dimen- sion highly relevant to reading achievement but not directly related to general ability as usually defined and measured.

Association with Reading and Spelling Difficulties

Children with heavy ‘neurological’ loadings in every case had severe reading and

MARJORIE WALKER

spelling difficulties, though certain children with a less heavy ‘neurological’ and perceptual/visuo-spatial/coding loading had no reading difficulty. There was no consistent association of any particular ‘neurological’ feature with the reading disability. In the children who had no reading and spelling difficulties there was no consistent pattern of assets and handi- caps, and it could only be supposed that in these cases the total assets, which must include such things as good and flexible teaching, stability, good home environ- ment, etc.-factors not assessed in this study-had been sufficient to pull them through.

Comparison with Matched Controls When the children were matched from

the cross-sectional group for chronological age and Vocabulary level, and for chronological age and Matrices Age, the difference in the findings in the two groups was striking. The controls had a very wide range of scores: some had very mixed scores, others tended to be on the good side, others again on the weak side, with always at least one or two good scores in each child, but with a small number of children showing one, two or even three scores with a rank order of below 20.

Sex Incidence The proportion of boys in the ‘neuro-

logical’ group is high (1 1 boys to 5 girls). Of the ‘fails’ on the finger gnosia test, five were boys and four were girls, though this is not meaningful without ages and age norms. But more instructive are the results on the Oseretsky, which showed some deficit, in most cases a marked one, in all the 11 boys but in only 1 of the 5 girls, all the others performing at their age levels. All the 6 ‘fails’ on the Prechtl test were among these boys and, further- more, these were the children with the most widespread and serious deficits on Oseretsky. Without allowance for age it is difficult to interpret the findings for associated movements. It is nevertheless of interest that all the Prechtl ‘fails’ ranked low (rank order of 20 or under) for associated movements (a low rank order indicates poor performance), and that 8 of the 12 who ranked at this level were boys.

Acknowledgements: I am indebted to Miss Margaret Procter, Senior Educational Psychologist, Inner London Education Authority, for initiating this investigation; to Dr. Elizabeth Warrington for giving and evaluating the finger gnosia tests; to Dr. Moya Tyson for her valuable suggestions; and to the children and staff of the schools concerned for their generous co-operation. This research is being supervised by Professor Brian Foss, Institute of Education, London University, who has given unfailing help and encouragement.

SUMMARY Perceptual, coding, visuo-motor and spatial difficulties in 33 primary school children

were found to be scattered sporadically throughout the entire group, but in increasingly heavy loadings. There was no consistent association of any particular difficulty with finger agnosia, synkinesis, the Prechtl phenomenon or poor motor ability, but where the specific difficulties were extensive the ‘neurological’ disabilities were marked, and in every case there were associated reading and spelling problems. The most severely affected children were boys. There appeared to be no direct relationship between this physiological- neurological continuum and that of general intellectual ability.

RBSUME Les diJ?cultds de perception, de code, d’ordre visuo-moteur et spatial et leurs

correspondants neurologiques: une note de laboratoire Dans un groupe de 33 Blbves d’Ccole primaire on a trouvC que les difficult& de perception

et de code et les difficult& d’ordre visuo-moteur et spatial ttaient rtparties au hasard et

547


sporadiquement dans le groupe entier, mais en groupements de plus en plus importants. Aucune de ces difficult6s n’6tait associCe de faqon consistante avec l’agnosie digitale, la synkintsie, le phtnombne de Prechtl, ou la faiblesse des facultes rnotrices, mais 18 o i ~ les difficult& spkifiques ttaient ttendues, les infirmitCs ‘neurologiques’ ttaient marquCes, et des problbmes surgissaient dans chaque cas pour lire ou apprendre l’orthographe. Les enfants les plus stvbrement atteints Ctaient les garqons. I1 ne semble pas exister de relation directe entre cet ensemble physiologico-neurologique et celui des facultCs intellectuelles gbntrales.

ZUSAMMENFASSUNG Perceptive, codische, visuo-motorische und spatielle Schwierigkeiten und deren

neurologische Korralate: ein Fortschrittsbericht Perceptive, codische, visuo-motorische und spatielle Schwierigkeiten bei 33 Elementar-

Schulkindern wurden sporadisch gestreut in der ganzen Gruppe festgestellt, jedoch in zunehmend schweren Ladungen. Es trat keine konsistente Assoziation einer besonderen Schwierigkeit mit Finger-Agnosie, Synkinesis, dem Prechtl-Phanomen oder schwacher motorischer Fahigkeit auf, aber wo die spezifischen Schwierigkeiten bedeutend waren, waren die ‘neurologischen’ Behinderungen markant, und in jedem Fall gab es mit diesen assoziierte Lese-und Rechtschreibungsprobleme. Die am schwersten betroffenen Kinder waren Jungen. Es schien keine direkte Beziehung zwischen diesem physiologisch-neurologischen Kontinuum und der allgemeinen intellektuellen Fahigkeit zu bestehen.

RESUMEN Dijicultades de percepcidn, de codijicacidn, visuo-motores y espaciales, y sus

correlaciones neuroldgicas: una nota de progreso En 33 niiios en escuelas primarias, se encontraron dificultades de percepcibn, de

codificacibn, visuo-motores y espaciales, esparcidas espor8dicamenteY per0 cada vez m8s considerables, por el grupo entero. Ninguna dificultad especial se asociaba consistentemente con la agnosia digital, el movimiento asociado, el fendmeno de Prechtl ni con una capacidad motor deficiente, per0 cuando las dificultades especificas eran grandes, las incapacidades motores eran notables, y en todos 10s casos habian problemas asociados de lectura y de ortografia. Los niiios m8s afligidos eran machos. A1 parecer, no habia una relacion directa entre este continuo fisiol6gico-neurologico y la capacidad intelectual en general.

REFERENCES Benton, A. L. (1959) Right-Left Discrimination and Finger Localization: Development and Pathology.

- (1955) The Revised Visual Retention Test. Iowa City: State University of Iowa. Frostig, M. (1961) A Developmental Test of Visual Perception. Kinsbourne, M., Warrington, E. K. (1962) ‘A study of finger agnosia.’ Brain, 85, 47. Newsom, E. (1955) The Development of Line Figure Discrimination in the Pre-School Children. Notting-

Prechtl, H. F. R., Stemmer, C. J. (1962) ‘The choreiform syndrome in children.’ Develop. Med. Child

Zangwill, 0. L. (1960) Cerebral Dominance and its Relation to Psychological Function. Edinburgh:

Zazzo, R. (1960) Manuel pour 1’Examen Psychologique de 1’Enfant. Neuchitel: Delachaw et Niestl6.

New York: Hoeber.

ham University Ph. D. thesis.

Neurol., 4, 119.

Oliver and Boyd.

548

Perceptual, Coding, Visuomotor and Spatial Difficulties and their Neurological Correlates: a...

Documents

Transcript of Perceptual, Coding, Visuomotor and Spatial Difficulties and their Neurological Correlates: a...