Effect of Goal-Directed Perceptual-Motor Exercise on Children with Specific Learning Difficulties: A Randomized Controlled Trial

doi:10.21203/rs.3.rs-4669390/v1

Download PDF

Research Article

Effect of Goal-Directed Perceptual-Motor Exercise on Children with Specific Learning Difficulties: A Randomized Controlled Trial

https://doi.org/10.21203/rs.3.rs-4669390/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

A comprehensive literature review has demonstrated that incorporating perceptual interventions into motor exercises is beneficial. Although there are several treatment strategies for SLD-diagnosed children, the potential role of goal-directed perceptual-motor exercises has not been studied. This study examined the effectiveness of goal-directed perceptual-motor training on attention, motor skills, and quality of life in children with Specific Learning Disorder (SLD).

Methods

This was a randomized clinical study with 38 children diagnosed with SLD between September 2021 and April 2022. The control group (n = 19) received a standard intervention protocol and the intervention group (n = 19) additionally received a perceptual-motor training program. Burdon Attention Test, the Bruininks-Oseretsky Test 2–Short Form (BOT2- SF), and the Pediatric Quality of Life Inventory (PEDSQL) were used as outcome measures.

Results

The intervention significantly improved attention, fine and gross motor skills, and life quality as evidenced by the within- and between-group comparisons at the end of therapy.

Conclusions

Goal-directed perceptual-motor physical training with cognitive aspects may enhance academic performance, social participation, and life quality for children with SLD by improving basic motor skills. Therefore, the inclusion of physical and task-specific perceptual-motor exercises in educational programs may offer several avenues for cognitive skill development in SLD children.

Trial Registration:

The protocol is registered with http://clinicaltrials.gov/ (16/August/2023, Clinical Trial, NCT05998083).

Attention Deficit Disorder

Child Public Health

Exericse

Phsical Activity

Physiotheraphy

Specific Learning Disorder (SLD) is a condition in which an individual, despite having a normal or above-normal level of intelligence, performs below expected levels of academic achievement.(1) Children with SLD exhibit deficits in executive functioning, including memory, attention, and reasoning, despite exhibiting normal intelligence.(2) It is well known that children with SLD have poor motor skills(3), including deficits in postural control, visual-motor coordination, and gross and fine motor skills.(4) Additionally, children with SLD typically have fine motor problems, including difficulties in bimanual coordination, dexterity, and fine motor skills.(5) Their gross motor performance such as coordination, balance, running, and jumping, is also weaker than typical children's.(6)

Executive functions involve cognitive processes such as planning, organization, attention, and remembering details.(7) Children with SLD typically exhibit lower executive function performance such as working memory, attention, planning, and problem-solving.(2) There is a correlation between motor performance and higher-order cognitive functions, specifically executive functioning.(8) Executive functions cover higher-level cognitive functions necessary for goal-directed behavior and attention. The inability to maintain task attention is also a key difficulty for people with SLD.(9) It is evident that attention plays a significant role in cognitive performance, memory retention, and learning behavior. Minor attentional deficits have been shown to impair learning, emphasizing the importance of maintaining optimal levels of attention for optimal learning outcomes.(10) In addition, planning and problem-solving skills are critical components of goal-directed behavior and involve planning actions and approaching a task in an organized, strategically efficient manner.(11)

Another characteristic feature of SLD is significant limitations in health-related quality of life (HRQoL). The HRQoL covers various subcategories, such as physical, emotional, social, and school functioning.(12) These functional skills, relevant to most daily tasks at home and in the community, are linked to physical well-being and fitness.(13) Children with SLD encounter difficulties in activities of daily living, including dressing, climbing stairs, running, and basic motor skills. These limitations impede their ability to participate in plays with their peers and in leisure activities at home, school, or the community.(14)

Evidence shows that perceptual-motor and physical activity programs improve cognitive, motor, and academic skills in SLD children.(15) Previously, the incorporation of physical and motor activities has been shown to provide several learning opportunities for children with autism spectrum disorders that facilitate the optimal development of cognitive abilities in children.(16) However, there is still a need for further investigation into the impact of perceptual-motor exercise and different physical activity interventions on children's mental and physical well-being and abilities.(16) Therefore, the present study aims to investigate whether a task-specific perceptual-motor intervention program could simultaneously improve motor abilities, attention, and HRQoL in children with SLD.

The study design was a parallel randomized controlled trial. The protocol is registered with http://clinicaltrials.gov/ (16/August/2023, Clinical Trial, NCT05998083). The study received ethical approval from the Üküdar Non-Interventional Research Ethics Committee under decision number 61351342/ August 2021-28 following the Declaration of Helsinki and “Regulations in Drug Research Ministry of Health, Government of Turkey, January 29, 1993. Children and their parents were informed about the study. Furthermore, all parents completed the Informed Voluntary Consent Form, signed it, and gave their consent.

The sample size was calculated with an 80% confidence interval using a large effect size (Cohen’s d = 0.8) Burdon attention test using G*Power version 3.1.9.7. assuming a drop-out rate of 10%, 20 children were needed in each group to have 80% power to detect this difference at the .05 significance level (α). Therefore, we estimated the sample size to be 40 children (20 per group).

Participants

This study involved 40 children with learning difficulties aged between 7 and 17 who were registered at the Private Umutışığım Special Education and Rehabilitation Centre in Kocaeli. We excluded children with physical or mental disorders in addition to the diagnosis of SLD. Two children dropped out of the study: one moved to another city, and the other did not complete the therapy. The study was completed with a total of 38 participants (Fig. 1). The children's diagnoses were obtained from their medical reports.

Figure 1. CONSORT flowchart.

Randomization

Participants were randomly allocated into two groups as intervention and control groups using the block randomization method with the assistance of Random Allocation Software. The participants and the evaluator were not blinded in group allocation.

Intervention

Both groups received a standard intervention. The intervention group additionally received a perceptual-motor training program.

Control Group

Participants in the control group received personalized educational support programs. Standard intervention includes academic curriculum such as Turkish, Mathematics, Preparation of Learning, Social Skills, and Developmental Language Intervention with a special education teacher in a Special Education and Rehabilitation center for 2 days a week.

Intervention Group

In addition to the standard intervention, the intervention group received perceptual-motor training twice a week for 8 weeks, with each session lasting 40 minutes (Fig. 2). These exercises consisted of a warm-up (10 minutes), goal-oriented balance and coordination exercises in a parkour (20 minutes), and cool-down exercises (10 minutes). The motor perception program was individually delivered under supervision. This program was designed to improve participants' motor skills, remembering, and attention span together. In the practice program, the child was first shown a Lego shape and asked to remember it. Then the child completed the 5-station parkour, including a hopscotch station, a single-line tandem walking station, a bounce station, a ping-pong ball throwing station, and eight running stations. When the parkour was complete, they were asked to make the Lego shape shown at the beginning. Details of the intervention are given in the Consensus on Exercise Reporting Template. (17) (Supplementary File 1).

Figure 2. Perceptual-motor training. A. Hopscotch station, B. Tandem walking station on a single-line, C. Bounce station, D. Station for throwing table tennis balls into a bucket, E. Eight running stations, F. Recall the form shown before the parkour.

Assessment

The diagnosis, age, and gender of the children, as well as the education level, income, and age of their parents, were recorded.

Attention skills were assessed using the Burdon Attention Test, and motor skills were measured with the Bruininks-Oseretsky Test 2 – Short Form (BOT2 - SF) Motor Competence Test, and independence in daily life was evaluated using the Pediatric Quality of Life Inventory (PEDSQL). All measurements were administered to the intervention and control groups before and immediately after the intervention.

Burdon Attention Test

There are two kinds of Burdon attention tests. The first requires identifying and indicating specific letters in mixed typefaces while the latter needs identifying and characterizing specific shapes within a given mixture of shapes. In this study, we used the Burdon Attention Test Letter Form. Children were asked to find and mark the letters "b, d, g, and p" as quickly as possible. We determined the attention score based on the number of correctly identified letters by the participants. The highest achievable score for the test is 110, and all participants are allocated six minutes for the examination. The Turkish validation study was conducted by Karaduman et. al.(18)

Bruininks-Oseretsky Test 2 – Short Form (BOT2 - SF)

BOT2 is a motor assessment tool for individuals between 4 to 21 years old. The test assesses fine and gross motor skills using eight subtests with 12 motor items (Table 1). It takes 15–20 minutes to administer the test to the child. The maximum score that can be obtained from this test is 72, and the higher the score means, the better motor performance. The Turkish validation study was conducted by Köse et. al.(19).

Table 1

Sub-parameters of Bruininks-Oseretsky Test 2.
Sub-skill	Instruction	Point Range
Fine Motor Accuracy	1- Colour the interior of a star-like shape	0–3
Fine Motor Accuracy	2- Trace a specific path without exceeding the outer boundaries	0–7
Fine Motor Integration	3- Copy a nested circle	0–6
Fine Motor Integration	4- Copy a diamond figure	0–5
Manuel Dexterity	5- Stringing block cubes	0–10
Bilateral Coordination	6- Touch the tip of the nose with the index finger (eyes closed)	0–4
Bilateral Coordination	7- Make a square with the thumb and forefinger.	0–3
Balance	8- Walking on a line from heel to toe	0–4
Speed and Agility	9- Jumping on one foot	0–10
Coordination of Upper Extremities	10- Catching a thrown ball (with one hand)	0–5
Coordination of Upper Extremities	11- Bouncing the ball with both hands.	0–5
Endurance	12- Full push-ups and push-ups on knees	0–10

Pediatric Quality of Life Inventory (PedsQL 4.0)

The PedsQL has psychometric properties and is useful for measuring psychosocial functioning in children with disabilities. The questionnaire consists of 23 items and is a 5-point Likert scale. The PedsQL includes four sub-domains of functioning: physical (8 items), emotional (5 items), social (5 items), and school (5 items). The items are reverse scored and then calculated linearly from 0 to 100 (0 = 100, 1 = 75, 2 = 50, 3 = 25, 4 = 0). Higher scores indicate a better quality of life. In our study, children answered the questions themselves. Turkish validation and reliability were performed by Çakın Memik et. al.(20).

Statistical Analyses

All analyses were performed using SPSS v24 (IBM Corp.). Descriptive statistics were used to summarise participant characteristics. The normal distribution of the data was determined using the Kolmogorov-Smirnov test. An independent t-test was used to compare groups, and a dependent t-test was used to compare pre-and post-test results within groups. Effect sizes were calculated using Cohen's d-test when significance was found in the between-group pre-test and post-test comparisons.

This was a randomized clinical study with 38 children diagnosed with SLD between September 2021 and April 2022. At the beginning of the study, 1 person from each group was not included in the study because they did not complete the exercises or trainings. At the end of the study, demographic data of the intervention (n19) and control (n:19) groups are as shown in Table 2. There was no significant difference between the groups in the demographic data of the participants (p > 0.05).

Table 2

Demographics of All Participants.
		Intervention Group (n:19)	Control Group (n:19)
Age (year)		10.84 ± 2.03	10.21 ± 1.93
Length (cm)		139.42 ± 9.69	135.42 ± 9.79
Weight (kg)		37.32 ± 8.19	32.74 ± 8.61
BMI (kg/m²)
Sex	Boy	8	12
Sex	Girl	11	7
Special Education Support (year)	2	9	6
	3	9	10
	6	1	1
	7	0	2

Table 3 compares the levels of attention, motor abilities, and life quality between the two groups before and after therapy. In group analyses, the intervention group showed a significant improvement in attention (p < 0.001), motor skills (p < 0.001), and life quality (p = 0.003) at the end of therapy. In contrast, the control group showed no significant differences in any parameter before and after the treatment. In the between-group analyses; the intervention group showed statistically significant improvements with a large effect size in attention (p < 0.001), motor skills (p < 0.001), and life quality (p = 0.005) compared to the control group.

Table 3

The Comparison of Attention, Motor Abilities, and Life Quality Between the Groups.
	Intervention Group			Control Group			Group Comparison
	T0	T1	p^a	T0	T1	p^a	p_T0	p_T1	Cohen’s d
Burdon	84.13 (3.95)	96.86 (2.55)	0.000***	85.43 (3.66)	85.65 (3.67)	0.172	0.935	0.000***	1.080
BOT2-SF	49.68 (5.21)	53.42 (3.99)	0.000***	47.42 (4.19)	47.63 (4.20)	0.331	0.150	0.000***	1.091
PedsQL	37.95 (7.84)	40.68 (9.00)	0.003***	32.84 (7.61)	32.63 (7.32)	0.531	0.049	0.005***	1.000

Burdon: Burdon Attention Test, BOT2-SF: Bruininks-Oseretsky Test 2 – Short Form (BOT2 - SF), PedsQL: Pediatric Quality of Life Inventory, T0: Before the Therapy, T1: After the Therapy, p^a: In group analyses by using dependent t-test, p^T0: Group comparison before the therapy by using independent t-test, p^T1: Group comparison after the therapy by using independent t-test, ***p < 0.001.

The present study aimed to investigate the effect of goal-directed perceptual-motor interventions on attention, motor skills, and life quality in children with SLD. In this study, an eight-week perceptual-motor exercise was shown to significantly improve children's attention, motor abilities, and life qualities with large effect sizes.

SLD children exhibit motor difficulties, including postural control, gross and fine motor function, visual-motor control, dynamic balance, and bilateral coordination issues.(21) Perceptual-motor exercises may benefit cognitive, motor, and school performance in children diagnosed with SLD.(15) The 24-session ABC learning approach, developed by Blythe, has been reported to collectively improve motor, working memory, attention, and problem-solving skills, as well as attention, balance, and coordination skills in children.(22) Previously, 16 sessions of motor intervention on motor, cognitive problem-solving, and academic achievement demonstrated significant improvements in motor skills, but no change in cognitive skills. The motor intervention included ball skills such as balance and coordination, with no cognitive requirements.(23) In contrast to the findings of our previous study(23), which indicated that perceptual-motor intervention could lead to significant improvements only in motor skills, our current study demonstrated that 16 sessions of this intervention can enhance motor abilities, including fine motor skills, coordination, balance, and attention skills, in children with SLD.

Gross motor competence is positively associated with children's cognitive functioning, including academic performance and executive functioning. There is a positive correlation between perceptual-motor function and sustained and self-directed attention.(24) Our study found a significant improvement in attention in the intervention group, with a large effect size. Perceptual-motor exercises consist of tracks that require the use of visual-spatial perception, balance, and coordination skills, where the user finds the most functional option among several options.(25) The theory of embodied cognition describes well that performing motor skills also activates cognitive skills.(26) Cofini et. al. reported that an 18-session (once-a-week) dance program significantly improved cognitive function, including attention and concentration, in children with SLD.(27) In this present study, 16 sessions of perceptual-motor training improved attention skills in children with SLD, consistent with previous research. Therefore, we demonstrated that an optimal motor intervention for children with SLD can improve cognitive tasks, such as sequencing, motor planning, and remembering game steps, to enhance attention skills.

HRQoL was also assessed in our study. We found a significant improvement in life quality in the intervention group. HRQoL is a multidimensional framework that addresses the subjective assessment of an individual's healthy functioning in physical, mental, emotional, and social domains.(13) Children with SLD show significant difficulties including social and school functioning and emotional and physical well-being. Children with low motor skills are less preferred by their peers, both in play and in the classroom. These children may also prefer not to participate in social and school activities. There is strong evidence that motor interventions improve physical self-perception, which is accompanied by enhanced self-esteem.(28) School-based physical activity programs that support active lifestyles in children and adolescents can help improve the HRQoL.(29) This study suggests that goal-directed perceptual-motor exercises may improve the motor skills of children with SLD, which could lead to increased participation in activities that impact their quality of life, including physical, mental, emotional, and social functioning.

The strength of our study lies in its examination of motor and cognitive function, as well as quality of life, following the International Classification of Functioning, Disability and Health (ICF). However, our study had some limitations. Due to the nature of our study, participants and the evaluator were not blinded in group allocation. Additionally, we did not collect data on participants' leisure activities during the study. Thus, the potential impact of environmental factors cannot be disregarded. Our study population, although sufficient in number according to the power analysis, was still relatively small. Although one-on-one perceptual-motor intervention is highly effective, it may have limitations in terms of dissemination. Therefore, we suggest that future studies explore interventions in school settings and/or groups.

In conclusion, an effective motor intervention for children with SLD would improve cognitive tasks such as sequencing, motor planning, and remembering game steps to improve attention skills. Also, goal-directed perceptual-motor training that includes cognitive elements such as remembering the sequence of activities, motor planning, and directing attention that require basic motor skills may help children with SLD improve their academic performance, social participation, and quality of life.

SLD: Specific Learning Disorder

BOT2- SF: Bruininks-Oseretsky Test 2–Short Form

PEDSQL: Pediatric Quality of Life Inventory

HRQoL: Health-related quality of life

Ethics approval and consent to participate: The study received ethical approval from the Üküdar Non-Interventional Research Ethics Committee under decision number 61351342/ August 2021-28 following the Declaration of Helsinki and “Regulations in Drug Research Ministry of Health, Government of Turkey, January 29, 1993. Children and their parents were informed about the study. Furthermore, all parents completed the Informed Voluntary Consent Form, signed it, and gave their consent.

Consent for publication: Children and their parents were informed about the study. Furthermore, all parents completed the Informed Voluntary Consent Form, signed it, and gave their consent.

Availability of data and materials: Data sets generated during the current study are available from the corresponding author upon reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable.

Authors' contributions: EP and ÖŞ analyzed and interpreted the patient data. TA was a major contributor to writing the manuscript. All authors read and approved the final manuscript.

Acknowledgments: Not applicable.

Cooper R. Diagnostic and statistical manual of mental disorders (DSM). Vol. 44, Knowledge Organization. 2017.
Poletti M. WISC-IV Intellectual Profiles in Italian Children With Specific Learning Disorder and Related Impairments in Reading, Written Expression, and Mathematics. J Learn Disabil. 2016;49(3).
Haslum MN, Miles TR. Motor performance and dyslexia in a national cohort of 10-year-old children. Dyslexia. 2007;13(4).
Maïano C, Hue O, April J. Effects of motor skill interventions on fundamental movement skills in children and adolescents with intellectual disabilities: a systematic review. Vol. 63, Journal of Intellectual Disability Research. 2019.
Logan SW, Robinson LE, Wilson AE, Lucas WA. Getting the fundamentals of movement: A meta-analysis of the effectiveness of motor skill interventions in children. Vol. 38, Child: Care, Health and Development. 2012.
Barnett LM, Lai SK, Veldman SLC, Hardy LL, Cliff DP, Morgan PJ, et al. Correlates of Gross Motor Competence in Children and Adolescents: A Systematic Review and Meta-Analysis. Vol. 46, Sports Medicine. 2016.
Demetriou A, Spanoudis G. From cognitive development to intelligence: translating developmental mental milestones into intellect. Vol. 5, Journal of Intelligence. 2017.
Bidzan-Bluma I, Lipowska M. Physical activity and cognitive functioning of children: A systematic review. Vol. 15, International Journal of Environmental Research and Public Health. 2018.
Westendorp M, Hartman E, Houwen S, Smith J, Visscher C. The relationship between gross motor skills and academic achievement in children with learning disabilities. Res Dev Disabil. 2011;32(6).
Sterr AM. Attention performance in young adults with learning disabilities. Learn Individ Differ. 2004;14(2).
Roebers CM, Kauer M. Motor and cognitive control in a normative sample of 7-year-olds. Dev Sci. 2009;12(1).
Sakiz H, Sart ZH, Börkan B, Korkmaz BDLDAL, Babür N. Quality of Life of Children with Learning Disabilities: A Comparison of Self-Reports and Proxy Reports. Learning Disabilities Research and Practice. 2015;30(3).
Varni JW, Seid M, Kurtin PS. PedsQL^TM 4.0: Reliability and Validity of the Pediatric Quality of Life Inventory^TM Version 4.0 Generic Core Scales in Healthy and Patient Populations. Med Care. 2001;39(8).
Baldi S, Caravale B, Presaghi F. Daily motor characteristics in children with developmental coordination disorder and in children with specific learning disorder. Dyslexia. 2018;24(4).
Fathi Azar E, Mirzaie H, Jamshidian E, Hojati E. Effectiveness of perceptual-motor exercises and physical activity on the cognitive, motor, and academic skills of children with learning disorders: A systematic review. Vol. 49, Child: Care, Health and Development. 2023.
Schurink J, Hartman E, Scherder EJA, Houwen S, Visscher C. Relationship between motor and executive functioning in school-age children with pervasive developmental disorder not otherwise specified. Res Autism Spectr Disord. 2012;6(2).
Slade SC, Dionne CE, Underwood M, Buchbinder R, Beck B, Bennell K, et al. Consensus on exercise reporting template (Cert): Modified delphi study. Phys Ther. 2016;96(10).
Dilek Karaduman. The Effect of attention training program on fourth and fifth grade primary school students attention, self concept and achievement levels. [Ankara]: Ankara University; 2004.
KÖSE B, ŞAHİN S, KARABULUT E, KAYIHAN H. Turkish Version of Bruininks-Oseretsky Test of Motor Proficiency 2 Brief Form: Its Validity and Reliability in Children with Specific Learning Disability. Bezmialem Science. 2021;9(2).
Cakin Memik N, Ağaoğlu B, Coşkun A, Uneri OS, Karakaya I. [The validity and reliability of the Turkish Pediatric Quality of Life Inventory for children 13-18 years old]. Turk Psikiyatri Derg. 2007;18(4):353–63.
Westendorp M, Hartman E, Houwen S, Huijgen BCH, Smith J, Visscher C. A longitudinal study on gross motor development in children with learning disorders. Res Dev Disabil. 2014;35(2).
Emami Kashfi T, Sohrabi M, Saberi Kakhki A, Mashhadi A, Jabbari Nooghabi M. Effects of a Motor Intervention Program on Motor Skills and Executive Functions in Children With Learning Disabilities. Percept Mot Skills. 2019;126(3).
Westendorp M, Houwen S, Hartman E, Mombarg R, Smith J, Visscher C. Effect of a ball skill intervention on children’s ball skills and cognitive functions. Med Sci Sports Exerc. 2014;46(2).
Blythe SG. Early learning in the balance: Priming the first ABC. Support for Learning. 2000;15(4).
Goddard Blythe S. Attention, Balance and Coordination. Attention, Balance and Coordination. 2017.
Harbourne RT, Berger SE. Embodied Cognition in Practice: Exploring Effects of a Motor-Based Problem-Solving Intervention. Phys Ther. 2019;99(6).
Cofini V, Cianfarani A, Cecilia MR, Carbonelli A, Di Giacomo D. Impact of dance therapy on children with specific learning disability: A two-arm cluster randomized control study on an Italian sample. Minerva Pediatrics. 2021;73(3).
Lubans D, Richards J, Hillman C, Faulkner G, Beauchamp M, Nilsson M, et al. Physical activity for cognitive and mental health in youth: A systematic review of mechanisms. Vol. 138, Pediatrics. 2016.
Janssen I, LeBlanc AG. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Vol. 7, International Journal of Behavioral Nutrition and Physical Activity. 2010.

No competing interests reported.

SupplementaryFile1.docx

Download PDF

Reviewers agreed at journal
30 Jul, 2024
Reviews received at journal
24 Jul, 2024
Reviewers agreed at journal
15 Jul, 2024
Reviewers invited by journal
14 Jul, 2024
Editor invited by journal
09 Jul, 2024
Editor assigned by journal
05 Jul, 2024
Submission checks completed at journal
05 Jul, 2024
First submitted to journal
01 Jul, 2024

You are reading this latest preprint version

Effect of Goal-Directed Perceptual-Motor Exercise on Children with Specific Learning Difficulties: A Randomized Controlled Trial

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Trial Registration:

Figures

BACKGROUND

METHODS

Participants

Randomization

Intervention

Control Group

Intervention Group

Assessment

Burdon Attention Test

Bruininks-Oseretsky Test 2 – Short Form (BOT2 - SF)

Pediatric Quality of Life Inventory (PedsQL 4.0)

Statistical Analyses

RESULTS

DISCUSSION

CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1