Research in Developmental Disabilities 45–46 (2015) 373–383

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Impact of tactile function on upper limb motor function in

children with Developmental Coordination Disorder
Lauren E. Cox, Elizabeth C. Harris, Megan L. Auld, Leanne M. Johnston *
Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia

A R T I C L E I N F O A B S T R A C T

Article history: This study investigated the presence of, and relationship between tactile dysfunction and
Received 10 January 2015 upper limb motor function in children with Developmental Coordination Disorder (DCD)
Received in revised form 13 June 2015 compared to typical developing (TD) children. Participants were 36 children aged 6–12
Accepted 30 July 2015 years. Presence of DCD (n = 20) or TD (n = 16) was confirmed using the Movement
Available online 27 August 2015 Assessment Battery for Children, second edition. All children participated in a
comprehensive assessment of tactile registration (Semmes Weinstein Monofilaments);
Keywords: tactile spatial perception (Single Point Localisation (SPL) and two-point discrimination
Children
(2PD)); haptic perception (Stereognosis); speed of simple everyday manual tasks (Jebsen–
Developmental Coordination Disorder
Taylor Test of Hand Function (JTTHF)); and handwriting speed and accuracy (Evaluation
Tactile function
Upper limb motor function
Tool of Children’s Handwriting (ETCH)). Compared to TD children, children with DCD
Handwriting demonstrated poorer localisation of touch in the non-dominant hand (p = 0.04), slower
speed of alphabet writing (p < 0.05) and less legible handwriting (p < 0.01), but no
difference in speed of simple everyday manual tasks (JTTHF: p > 0.05). Regression analysis
showed that spatial tactile perception (SPL) predicted handwriting legibility (ETCH:
r = 0.11) and speed of functional tasks (JTTHF: r = 0.33). These results suggest that tactile
function, specifically single point localisation, should be a primary tactile assessment
employed to determine reasons for upper limb motor difficulties experienced by children
with DCD.
ß 2015 Published by Elsevier Ltd.

1. Introduction

Developmental Coordination Disorder (DCD) is a neurodevelopmental condition characterised by disordered motor

coordination (American Psychiatric Association, 2013). It is the most common motor disorder in childhood, affecting 5–6% of
children internationally (APA, 2013; Bair, Barela, Whitall, Jeka, & Clark, 2011). Males predominate with ratios ranging from
2:1 to 7:1 (APA, 2013; Miller, Missiuna, Macnab, Malloy-Miller, & Polatajko, 2001). Poor fine motor skills are one of the most
common coordination issues experienced, collectively causing significant functional impact at home, school and in
recreational environments (Miller et al., 2001; Polatajko & Cantin, 2006). In particular, parents and teachers frequently
identify poor handwriting in children with DCD (Chang & Yu, 2010; Miller et al., 2001; Smits-Engelsman, Niemeijer, & Van
Galen, 2001). This is a significant problem because 30–60% of the school day involves handwriting (McHale & Cermak, 1992)
and handwriting proficiency has been correlated with effective communication, self esteem and everyday function (Chang &
Yu, 2010; Feder & Majnemer, 2007). In order to produce accurate and coordinated upper limb movements for handwriting

* Corresponding author at: Division of Physiotherapy, Therapies Building, The University of Queensland, Brisbane, St Lucia, QLD 4072, Australia.
E-mail address: l.johnston1@uq.edu.au (L.M. Johnston).

http://dx.doi.org/10.1016/j.ridd.2015.07.034
0891-4222/ß 2015 Published by Elsevier Ltd.
374 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383

and dexterity tasks, integration of multisensory inputs is required (Elbasan, Kayihan, & Duzgun, 2012; Schoemaker et al.,
2001). Deficits in visual recognition (Sigmundsson, Hansen, & Talcott, 2003), visual perception (Maeland, 1992; Schoemaker
et al., 2001; Tsai, Wilson, & Wu, 2008) and proprioception (Laszlo, Bairstow, Bartrip, & Rolfe, 1988; Smyth, 1994) have been
well documented in children with DCD. However, although early literature has highlighted the importance of assessing
tactile function in the hands of children with DCD who have fine motor difficulties (Watter, 1996), only preliminary research
examining this relationship has been conducted. Tactile function is essential because it provides information regarding the
physical properties of an object which guides selection of magnitude, direction and timing of hand movements (Johansson &
Flanagan, 2009; Maeland, 1992). Therefore, the purpose of this study is to determine the characteristics of tactile function in
the hands of children with DCD and the potential influence on upper limb motor performance.
The paucity of literature investigating tactile function in children with DCD makes it difficult to determine the presence
and patterns of tactile deficits in the hands of children in this population. Tactile function is comprised of two phases –
registration and perception (Auld, Boyd, Moseley, & Johnston, 2011). Registration is the initial and basic detection of a tactile
stimulus and is the precursor to perception. Tactile perception encompasses the spatial, temporal and modality specific
components of a stimulus. In this phase the individual interprets and gives meaning to the sensory input based on where,
when and the quality of the stimulus (Auld, Boyd, Moseley, Ware, & Johnston, 2012; Auld, Ware, Boyd, Moseley, & Johnston,
2012). Both phases must be assessed to ascertain the level and severity of tactile impairment (Auld et al., 2011). In one
available study to date, no differences in registration were found between children with and without DCD when assessed
using Semmes Weinstein Monofilaments (Law, Lo, Chow, & Cheing, 2011). However two additional studies of spatial tactile
perception have demonstrated that children with DCD perform significantly worse on localisation of single and double
simultaneous stimuli, graphesthesia (Elbasan et al., 2012), identification of the fingers (Malloy-Miller, 1995) and two point
discrimination under both moving and static conditions (Law et al., 2011). This useful preliminary research suggests that
children with DCD experience predominately perceptual issues however further detail is required. For example, dermatomal
locations utilised for single and double simultaneous localisation were not specified in the Elbasan et al. (2012) study and
Malloy-Miller (1995) utilised a tactile assessment that was intended for a younger population (4–8 years-old) than the
participants of their study (7–12 years-old), leaving the possibility that tactile difficulties may be worse than measured.
These methodological factors require refining to improve valid and reliable representation of tactile function in children with
DCD.
Early research also suggests that children with DCD have difficulties with stereognosis compared to children with typical
development (TD). Stereognosis, otherwise known as haptic perception, is the ability to identify unseen objects with the
hand and is a motor-enhanced form of tactile perception involving tactile and proprioceptive inputs (Auld et al., 2011).
Deficits have been demonstrated using the Manual Form Perception (MFP) subscale of the Southern California Sensory
Integration Test (Elbasan et al., 2012) and during posting tasks with a stereognosis element (Schoemaker et al., 2001).
However, further work is required to determine the specific degree of haptic deficits that eliminate or control slow reaction
time, a common concomitant deficit identified in children with DCD (Mon-Williams et al., 2005; Wilmut, Byrne, & Barnett,
2013) and other efferent deficits in motor coordination.
Use of heterogeneous tactile assessments in studies of children with DCD makes it somewhat difficult to develop an
accurate understanding of tactile dysfunction in this population. A clinimetric review addressing this same issue for children
with cerebral palsy recommends a multi-dimensional assessment framework and test battery including tactile registration,
as well as spatial, temporal and stereognosis to comprehensively profile tactile function (Auld et al., 2011). Research using
this model is warranted for children with DCD, to determine the true nature and frequency of upper limb tactile deficits in
this population. Comprehensive tactile assessment also needs to be paired with assessment of upper limb motor function to
establish a clear relationship between these two elements.
Understanding the role of tactile function during motor tasks is critical to understanding deficits experienced by children
with DCD. It has been shown in typical populations that tactile afferents override visual cues after initial contact emphasising
their importance in manipulative tasks (Johansson & Cole, 1992; Johansson & Flanagan, 2009) and handwriting (Feder &
Majnemer, 2007; Yu, Hinojosa, Howe, & Voelbel, 2012). This data supports research in other paediatric populations with
motor disorders where tactile dysfunction has been shown to be a critical contributor to upper limb motor dysfunction
(Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012; Sakzewski, Ziviani, & Boyd, 2010). However, with the current studies
available it is difficult to establish a clear relationship between tactile function and upper limb function in the DCD
population. Law et al. (2011) assessed tactile registration and two-point discrimination alongside a motor task involving
picking up a cup, however the article appeared not to report the statistical relationship between sensory and motor
performance. A relationship between poor finger identification and handwriting execution was also found in children with
DCD (Malloy-Miller, 1995), however finger identification is potentially not the most discriminative tactile assessment (Auld
et al., 2011). Elbasan et al. (2012) found a relationship between graphesthesia and self-care on the WeeFIM1 (p < 0.01).
However, the WeeFIM1 describes global functional independence via a parent questionnaire and does not directly measure
quality (accuracy and speed) of upper limb function. Thus, further investigation is required to determine the relationship
between upper limb tactile and motor function in children with DCD.
This review has indicated a need for a more comprehensive examination of tactile function alongside motor function of
the hand in children with DCD. The primary aims of this study were therefore to investigate the characteristics of tactile
function in children with DCD compared to children with typical development (TD), and whether tactile function correlates
with upper limb motor function. Based on the current literature, it was hypothesised that (i) compared to children with TD,
 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383 375

children with DCD would demonstrate deficits in spatial and haptic tactile perception, but not registration of the hand, and
(ii) spatial deficits would be correlated with upper limb motor function in everyday manual tasks and handwriting.

2. Methods

2.1. Study design

A cross-sectional study design was utilised to examine tactile and motor performance of children with DCD and TD.
Children participated in the study as part of a larger study of sensory and motor function of children with motor disorders.
Ethical approval was obtained from the National Health and Medical Research Council (NHMRC) registered Human Research
Ethics Committees of the Cerebral Palsy League (EC#00417) and The University of Queensland (EC#00179).

2.2. Participants

Twenty children aged 6–12 years with DCD were recruited through a private physiotherapy clinic providing services for
children with DCD. Parents of eligible children were mailed an expression of interest flier, which described the study method.
The flier was followed within two weeks by a phone call to allow parents to ask questions. Children with parental consent
and child assent had their diagnosis confirmed according to DCD criteria (APA, 2013). First, parents were interviewed to
confirm that their child was experiencing significant functional problems as a result of their coordination difficulties and to
exclude presence of any known medical, intellectual or behavioural disorder. No children were excluded from the study at
this stage. Then, motor abilities of all potentially eligible children were screened using the Movement Assessment Battery for
Children, second revision (MABC-2) (Henderson, Sugden, & Barnett, 2007). The MABC-2 assessed motor skills in the domains
of manual dexterity, aiming and catching and balance (Henderson et al., 2007). Children who scored below the 15th
percentile were recruited to the DCD group, consistent with cut off criteria used in numerous studies to identify children
with DCD (Blank, Smits-Engelsman, Polatajko, & Wilson, 2012; Chang & Yu, 2010; Rosenblum & Livneh-Zirinski, 2008). All
children (n = 20) met this criteria.
Seventeen TD children were recruited as community volunteers. Typical motor performance was confirmed first by
interviewing parents to exclude presence of any known medical, intellectual or behavioural disorder. Then, by screening
their development to confirm that their motor performance was above the 15th percentile on the MABC-2. One child was
excluded due to orthopaedic problems of the upper limbs, resulting in a final group of 16 TD children. Prior to participation,
informed consent was obtained from each parent or guardian and assent was gained from each child.

2.3. Procedure

Each child participated in an evaluation of unilateral tactile function, upper limb motor function and handwriting
proficiency over one 90-min session.

2.3.1. Tactile function

Tactile function was assessed with a comprehensive tactile battery encompassing tactile registration and perception
items.

2.3.1.1. Registration. Registration was assessed utilising the full 20-item Semmes Weinstein Monofilaments (SWM) test
(Bell-Krotoski & Tomancik, 1987), applied at the palmer side of the distal phalanx of the thumb, index, 4th and 5th digit (Auld
et al., 2011; Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012). The score was the lowest SWM value (least force) that was
correctly detected on each of the four digits for at least one out of the three trials, and a sham trial (Auld et al., 2011; Auld,
Boyd, et al., 2012; Auld, Ware, et al., 2012). Normal light touch sensation of the hands and fingers is within monofilaments
one to four (log 1.65–2.83) (Bell-Krotoski & Tomancik, 1987). The SWM have excellent test–retest agreement within one
monofilament, in typically developing children and excellent reliability in children with motor difficulties (Auld, Boyd, et al.,
2012; Auld, Ware, et al., 2012).

2.3.1.2. Spatial perception. Single point localisation (SPL) (single-point unilateral, unidermatomal spatial perception), was
measured using the largest SWM (suprathreshold force) (Burns, 1992). Each of the dermatomes C6, C7 and C8 were assessed
three times (including the palmer, dorsal and medial or lateral sides of the digit) in a pseudorandom order, with the total
score out of 12. Normal sensation for typically developing children was a total score of 11 or greater (Auld, Boyd, et al., 2012;
Auld, Ware, et al., 2012). SPL has excellent test–retest agreement within one point, in typical developing children (Auld,
Boyd, et al., 2012; Auld, Ware, et al., 2012). This test also has excellent reliability in the non-dominant hand and good
reliability in the dominant hand in children with motor difficulties (Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012). Two
point discrimination (two-point unilateral, unidermatomal spatial perception) was assessed using the Disk-Criminator
(Auld et al., 2011; Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012; Mackinnon, Mackinnon, & Dellon, 1985). The stimulus was
applied statically to the palmer side of the distal phalanx of the index finger (2PD-Index) and thumb (2PD-Thumb) and the
final score was the smallest distance (in mm) between the two points that was correctly identified at least seven out of ten
376 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383

trials for each finger. Perceiving two points successfully at 3–5 mm separation was considered normal sensation (Auld et al.,
2011). The Disk-Criminator has been shown to have criterion validity with a strong correlation with object recognition
(Novak, Mackinnon, & Kelly, 1993). Static 2PD test has excellent test–retest agreement within one test point, in the typical
developing population (Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012). Reliability for this test is excellent in the non-
dominant hand and poor in the dominant hand, in children with motor difficulties (Auld, Boyd, et al., 2012; Auld, Ware, et al.,
2012).

2.3.1.3. Haptic perception. Stereognosis (the ability to identify unseen objects with the hand) was measured using a
combination of three stereognosis assessments. First, the Klingels’ protocol was used to assess the ability to recognise 12
common objects in the hand including six independent objects (key, clothes peg, comb, spoon, marble, ball) and six related
pairs (pencil and pen, paperclip and safety pin, coin and button) (Klingels et al., 2010). The total score was the number of
correct responses out of 12 for each hand. This test has good inter-rater reliability and excellent test–retest reliability in
children with motor difficulties (Klingels et al., 2010). However, a clinimetric review demonstrated a ceiling effect in children
with TD using this test, therefore additional stereognosis assessments with novel and complex objects were utilised in this
study (Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012). These stereognoisis assessments included the child’s ability to
recognise three-dimensional shapes, using Part I of the Manual Form Perception (MFP) subscale of the Sensory Integration
and Praxis Test (SIPT) (Ayres, 1989). Children were presented with 10 items (circle, star, triangle, square, octagon, hexagon,
diamond, trapezoid, cross, oval) in each hand and asked to identify each item on a printed display of the shapes. There was a
cut off time of 30 s and the total score was the number of correct responses out of five for each hand. This assessment has high
interrater reliability and moderate to high results for test–retest reliability (Ayres, 1989). Finally, a new test of perception of
two-dimensional geometric patterns was developed by the investigators (LMJ and MA). Children were presented with a
series of shapes embossed on foil that matched the stimuli presented in the Visual Perception subscale of the Visual Motor
Integration (VMI) test (Beery, 1997). In each trial, with vision occluded, the child was asked to palpate one embossed shape
(stimulus), and then identify this shape within a series of subsequent shapes on the foil (response). The score was the number
of correct trials before three sequential incorrect trials occurred. Preliminary research using this new stereognosis battery in
children aged 8–12 years, demonstrated excellent reliability in the dominant hand and fair reliability in the non-dominant
hand (Auld, Tan, Marozza, & Johnston, 2014).

2.3.2. Upper limb motor function

2.3.2.1. Speed of everyday manual tasks. The Jebsen–Taylor Test of Hand Function (JTTHF) assessed the speed of unimanual
upper limb function across seven simple everyday manual tasks (Jebsen, Taylor, Trieschmann, Trotter, & Howard, 1969).
Three scores were obtained. A JTTHF-objects score was obtained for each of the dominant and non-dominant hands to reflect
the total time (seconds) taken to perform six functional tasks (card turning, picking up small objects with fingers, picking up
small objects with a spoon, stacking checkers, picking up light cans, picking up heavy cans). Then, a JTTHF-writing score was
obtained to reflect the time taken (seconds) to complete a writing task, with the dominant hand only. Moderate to high
reliability is reported for the JTTHF across the seven subtests in adults (Jebsen et al., 1969) and this assessment been used to
measure unimanual capacity in children with motor dysfunction (Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012; Sakzewski
et al., 2010). Prior to administration of the JTTHF, hand dominance was determined utilising the Edinburg Handedness
Inventory (Oldfield, 1971).

2.3.2.2. Handwriting. Handwriting legibility and speed was evaluated utilising the Evaluation Tool of Children’s Handwriting
(ETCH) which is a valid and reliable tool for evaluating the handwriting of school-age children aged 6–12 years (Amundson,
1995; Diekema, Deitz, & Amundson, 1998; Duff & Goyen, 2010). This tool assessed six writing tasks including (i) alphabet
writing in upper and lower case, (ii) numeral writing, (iii) near and (iv) far point copying of a sentence, (v) a dictation task and
(vi) sentence composition. Outcome measures were legibility of words, letters and numerals assessed as the percentage
correct across the six tasks and speed (letters per minute) for each of the writing tasks except the dictation subtest
(Amundson, 1995).

2.4. Statistical analysis

Statistical analysis was performed using STATA 13 statistical software (StataCorp, 2013). Significance was set at p < 0.05
for all analyses. Once children were allocated to DCD and TD groups, means (standard deviations) and independent sample
t-tests were calculated to establish baseline separation between groups on MABC-2 total and subsection scores. A Fisher’s
exact test was used to examine equality between groups for gender ratio and hand dominance. Age was compared using a
t-test.
Each of the seven tactile variables (Registration; SPL; 2PD-index; 2PD-thumb; Stereognosis-objects; Stereognosis-
manual forms; Stereognosis-geometric shapes) and eight motor variables (JTTHF-objects; JTTHF-writing; ETCH-legibility;
ETCH-speed; MABC-2 total and three subsections) were examined for normality and transformations were performed if
required. Wilcoxon Rank Sum analyses were used to examine differences between groups on variables that were not
normally distributed (Registration, SPL, 2PD-index, 2PD-thumb and Stereognosis-objects). Independent sample t-tests were
 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383 377

used to examine differences between groups on normally distributed variables (Stereognosis-manual forms and
Stereognosis-geometric shapes). For variables that showed differences between groups overall, further subgroup
comparisons were performed after participants were stratified by age into a younger (6–8 years) and older groups
(9–12 years).
To assess the relationship between upper limb motor function (JTTHF and ETCH variables) and group (DCD or TD), linear
regressions were performed, adjusting for the covariates of age and gender if they were significant in the model (p < 0.05). To
examine the association between tactile and upper limb motor function multivariable regressions were performed. Each
upper limb motor outcome (JTTHF-object, JTTHF-writing, ETCH-legibility and ETCH-speed, MABC-2 by total and subsection
scores) was run against the seven tactile variables and two demographic variables (age, gender). Predictor variables were
discarded if they did not contribute significantly to the model (p > 0.05). All the assumptions for linear regression (normality
and constant variance of residuals and outliers) were satisfied and multicollinearity amongst the independent variables was
examined in post analysis checking.

3. Results

3.1. Participants

Baseline analyses demonstrated no significant differences between groups for age or hand dominance. There was a
significant difference between the groups for gender with males predominating in the DCD group, consistent with
international population data (APA, 2013). A significant difference between groups across all MABC-2 total and subsection
scores was also confirmed (p < 0.01) indicating a clear separation in motor performance between groups as required (see
Table 1).

3.2. Tactile registration and perception

Overall, tactile function was not significantly different between groups for most measures (p > 0.05) (see Table 2). The
exception was SPL, with TD children showing superior performance in the non-dominant hand compared to children with
DCD (p = 0.04). A similar trend was found for the dominant hand, but this did not quite reach statistical significance (p = 0.06).
From the raw data, it was clear that 50% of children with DCD performed below the normal range for SPL in their non-
dominant hand and 30% for their dominant hand. When SPL was stratified by age, young children with DCD (aged 6–8 years)
performed significantly worse than young children with TD in the non-dominant hand (p = 0.01) with a similar, but not
significant trend in the dominant hand (p = 0.09) (see Table 3). However, no significant difference was observed between
older children with DCD and TD (p > 0.7). As expected, young children with DCD performed worse than older TD children in
both hands (p < 0.01). It was also found that older children with DCD performed at the same level as young children with TD
(p > 0.4).

3.3. Upper limb function

3.3.1. Speed of everyday manual tasks (JTTHF)

Overall, there was no significant difference between children with DCD and TD for JTTHF-objects or JTTHF-writing. Age
was included in all models as a covariate because the JTTHF is not standardised for age, however the covariate gender was
insignificant and therefore discarded. As inverse transformations of JTTHF data were performed, the relationship of the
coefficient is opposite to the reported sign (see Table 4).

3.3.2. Handwriting (ETCH)

Compared to children with TD, children with DCD demonstrated poorer handwriting legibility for words (p = 0.003) and
letters (p < 0.001) (see Table 4). However, there was no significant difference between groups for numeral legibility
(p = 0.57). DCD group was a significant predictor of slower writing speed (characters per minute) for lower case (p = 0.021)

Table 1
Participant characteristics by TD and DCD groups.

TD group (n = 16) DCD group (n = 20) t p-value

Gender (M:F) 6:10 15:5 – 0.026

Dominance (L:R) 2:14 3:17 – 0.610
Age (mean (SD)) 8.69 (2.24) 8.35(1.63) 0.52 0.605

MABC-2a Mean (SD) Mean (SD)

Total 43.4 (20.5) 2.9 (3.03) 8.75 <0.001
Manual dexterity 44.2 (27.68) 5.5 (8.12) 5.96 <0.001
Aiming and catching 48.3 (34.37) 17.7 (16.89) 2.50 <0.001
Balance 39.4 (19.69) 9.6 (15.82) 5.05 <0.001
a
MABC-2 percentile scores.
378 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383

Table 2
Comparison of tactile performance between children with DCD and TD for registration, spatial perception and stereognosis for (A) the dominant hand and
(B) the non-dominant hand.

Test Test range (lowest to highest score) Median (interquartile range) Comparisons between
groupsa

TD DCD z-score p-value

(A) Dominant hand

Registration 1–20 monofilament 2 (1–2) 2 (1–2.5) 1.02 0.31
Spatial perception
SPL 1–12 correct 12 (11–12) 11 (10–12) 1.87 0.06
2PD-Index 15–2 mm 2 (2–2) 2 (2–3) 1.37 0.17
2PD-Thumb 15–2 mm 2 (2–3) 2 (2–3) 0.52 0.60
Stereognosis
Common objects 1–12 correct 12 (12–12) 11.5 (11–12) 1.61 0.11
Manual forms 1–5 correct 3.2 (0.75)b 3.3 (0.86) b 0.41c 0.68c
Geometric patterns 4–28 correct 13.4 (3.48) b 12.6 (3.10) b 0.75c 0.46c

Test Test range (lowest to highest score) Median (interquartile range) Comparisons between
groupsa

TD DCD z-score p-value

(B) Non-dominant hand

Registration 1–20 monofilament 2 (1–2) 2 (1–2) 0.34 0.74
Spatial perception
SPL 1–12 correct 11.5 (11–12) 10.5 (9–12) 2.05 0.04
2PD-Index 15–2 mm 2 (2–2) 2 (2–3) 1.36 0.18
2PD-Thumb 15–2 mm 2 (2–3) 2.5 (2–3) 1.12 0.26
Stereognosis
Common objects 1–12 correct 12 (11–12) 11 (11–12) 1.22 0.22
Manual forms 1–5 correct 3.5 (0.97) b 3.4 (0.99) b 0.30c 0.76c
Geometric patterns 4–28 correct 12.6 (3.01) b 12.3 (3.42) b 0.34c 0.73c
a
Wilcoxon Rank sum test.
b
Mean (SD).
c
t-score and p-value.

Table 3
Differences between children with DCD and TD on single point localisation, after being stratified by
age.

TD group

Younger (6–8 years) Older (9–12 years)

DCD group
Younger (6–8 years) Dominant: Dominant:
z = 1.683, p = 0.09 z = 2.764, p = 0.006
Non-dominant: Non-dominant:
z = 2.479, p = 0.01 z = 2.653, p = 0.008
Older (9–12 years) Dominant: Dominant:
z = 0.726, p = 0.47 z = 0.299, p = 0.77
Non-dominant: Non-dominant:
z = 0.701, p = 0.48 z = 0.207, p = 0.84

and upper case (p = 0.01) letters. The covariates of age and gender did not contribute significantly to these comparison
models and were therefore discarded. There was no difference between groups for speed of writing numerals, near or far
point copying, or composing a sentence (all p > 0.05).

3.4. Relationships between tactile function and upper limb motor function

Overall, motor performance tended to be predicted by spatial tactile perception (SPL and 2PD) and/or stereognosis
performance (see Table 5 and Fig. 1).

3.4.1. Motor performance (MABC-2)

Better MABC-2 Total scores were related to better performance on spatial tactile perception (SPL) in the dominant (p = 0.006)
and non-dominant (p = 0.016) hands. Better MABC-2 Manual Dexterity subsection scores were also associated with better SPL
scores in the dominant (p = 0.01) and non-dominant (p = 0.004) hands. A significant positive association was found between
better MABC-2 Balance subsection scores and better SPL in the dominant hand (p = 0.005). Better stereognosis of manual forms
using the non-dominant hand predicted better MABC-2 Aiming and Catching subsection scores (p = 0.008). No other tactile
variable or the covariate of gender was significantly associated with motor skills across the three subtests or total score.
 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383 379

Fig. 1. Significant relationships between single point localisation (SPL) in the dominant hand and upper limb motor function variables: (A) ETCH-letter
legibility; (B) JTTHF-objects and (C) MABC-2 Manual Dexterity.

3.4.2. Speed of everyday manual tasks (JTTHF)

Better performance on spatial tactile perception (SPL) was associated with faster JTTHF-object time for the preferred hand
(p = 0.018). Additionally, 2PD-thumb was a significant predictor of JTTHF-writing (p = 0.005). Both models were adjusted for
age as a significant covariate. No other tactile variables or the gender covariate predicted upper limb motor function of the
dominant hand (all p > 0.05). No tactile variable predicted motor function of the non-dominant hand (all p > 0.05).
380 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383

Table 4
Comparison of motor performance on simple functional tasks (JTTHF) and handwriting (ETCH) between children with DCD and TD using linear regression
with age and gender incorporated as covariates.

Outcome TD mean(SD) DCD mean(SD) b 95% CI R2 value p-value

JTTHF
Object dominant handa 38.1(9.40) 43.8(15.59) 0.002 0.002 to 0.006 0.23 0.380
Object non-dominant handa 53.3(38.48) 54.1(24.05) 0.0001 0.00005 to 0.0003 0.17 0.173
Writingb 36.5(16.49) 50.9(38.74) 0.010 0.019 to 0.040 0.04 0.489

ETCH legibility
Lettersc 88.3(7.10) 73.2(16.21) 284,976.2 155,843.1 to 414,109 0.36 <0.001
Wordc 84.0(10.57) 62.8(24.56) 2644.923 937.058 to 4352.788 0.20 0.003
Numeralsc 86.3(14.85) 85.4(11.91) 75,827.79 82,112.99 to 233,768.6 <0.001 0.336

ETCH speed
Alphabet lower case 23.5(6.19) 18.9(8.63) 5.88 0.931 to 10.609 0.13 0.021
Alphabet upper case 24.8(9.53) 18.6(8.36) 7.433 1.940 to 12.925 0.16 0.010
Sentence composition 41.7(13.53) 34.6(20.19) 9.652 1.878 to 21.182 0.06 0.098
Numeral 35.5(9.05) 34.9(12.63) 2.074 4.974 to 9.122 <0.001 0.553
Near point copyingd 36.0(15.78) 35.3(20.12) 0.094 0.267 to 0.455 <0.001 0.601
Far point copyinge 36.5(13.58) 36.9(21.97) 0.103 0.964 to 1.169 <0.001 0.846
a
Inverse transformation and adjusted for significant covariate of age.
b
Inverse square root transformation.
c
Power transformation.
d
Log transformation.
e
Square root transformation.

Table 5
Significant relationships between tactile function of the dominant hand and dominant upper limb motor function using multivariable regression.

Assessment Models Motor outcome Tactile variable b 95% CI p-value R2 valuei

MABC-2 (bimanual) i Total score SPL 1.387 0.422 to 2.351 0.006 0.18
ii Manual Dexteritya SPL 0.039 0.675 to 0.009 0.010 0.16
iii Balance SPL 1.44 0.473 to 2.409 0.005 0.19

JTTHF i Objectsc SPLe 0.002 0.0004 to 0.0044 0.018 0.33

ii Writingd 2PD-Thumbe 0.027 0.009 to 0.0454 0.005 0.29

ETCH legibility i Wordf 2PD-Thumb g 1436.76 2491.4 to 382.1 0.009 0.46

ii Letterf SPL 83,454.76 11,139.2 to 155,770.3 0.025 0.11
iii Numeralf SPLg 96,916.76 29,216.03 to 164,617.5 0.007 0.21
2PD-Indexg 205,223.3 39,830.48 to 370,616.1 0.017
Stereognosis 194,163 67,756.21 to 320,569.7 0.004
(common objects)g
Stereognosis 96,170.71 8695.84 to 184,045.6 0.033
(manual forms)g

ETCH speed i Copying sentence 2PD-Indexh 0.381 0.053 to 0.71 0.024 0.14
(near distance)
h
ii Sentence composition Registration 6.56 12.197 to 0.924 0.024 0.41
2PD-Indexh 12.92 2.807 to 23.036 0.014

SPL – single point localisation, 2PD – two point discrimination.

Transformations: a inverse square root, b square root, c inverse, d inverse square root, f power.
Covariates: The covariates of gender and age were run in each model but were discarded if they were not significant – all significant covariates included are
stated e both models adjusted for the significant covariate of age, gadjusted for the significant covariate of gender, hadjusted for the significant covariate of
age, iadjusted R2 with presented value accounting for the covariates of age or gender as stated in the table.

3.4.3. Handwriting (ETCH)

Tactile function was significantly related to legibility and speed of handwriting. Better SPL scores were significantly
associated with better letter legibility (p = 0.025), and better 2PD-thumb scores (lower scores) were significantly related to
better legibility of words (p = 0.009). Numeral legibility was predicted by the tactile variables: SPL (p = 0.007), 2PD-index
(p = 0.017) and stereognosis of common objects (p = 0.004) and manual forms (p = 0.033). Word and numeral legibility
models were adjusted for the significant covariate of gender. Faster sentence copying at a near distance was significantly
related to poorer performance on 2PD-index (p = 0.024). Sentence composition speed was predicted by registration
(p = 0.024) and 2PD-index (p = 0.014). Age was a significant covariate, accounted for in both regression models for speed of
writing. No other tactile variables were significantly related to the speed of writing alphabet letters, numerals, or copying a
sentence at a far distance (all p > 0.05).
 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383 381

4. Discussion

This study demonstrated that although there may not be overt differences in tactile function between children with DCD
and TD as seen in populations with neurological injury (e.g. cerebral palsy), children with DCD do demonstrate specific
deficits in spatial perception in the hands that appear to be associated with deficits in fine motor performance.
Compared to children with TD, children with DCD displayed poorer localisation of touch (SPL) on fingers of their non-
dominant hand and a predisposition to poorer performance in the dominant hand. In fact, when children with DCD were
considered in isolation, it was evident that a substantial proportion fell below the average range for SPL, with 50% of the
cohort for the non-dominant hand and 30% of the cohort for the dominant hand demonstrating a spatial tactile impairment.
Hand dominance is usually decided in the second year of life with individuals naturally biasing the dominant hand in
everyday manual tasks (Gustafson & Chen, 2002). Therefore, the differences in tactile function between hands may be
related to tactile perceptual learning effects related to training of the dominant hand. Studies have shown that tactile
perception training of the dominant hand can improve performance on tactile tasks but is not completely transferable to
the non-dominant hand as it has a somatotopic specific component (Kaas, van de Ven, Reithler, & Goebel, 2013). This
corroborates with the results, as age appeared to play a substantial mediating role in tactile perception (SPL), where only
younger children with DCD (6–8 years) displayed significant difficulties compared to their TD peers, and no significant
differences between groups were measured after nine years. This may reflect a catch up in sensory development, the
provision of intervention, or the effect of cumulative handwriting practice by older children, which may foster improved
sensory awareness in the fingers in order to write without the need for visual monitoring (Schneck, 1991). As our study was
cross-sectional, further longitudinal research is required to determine the developmental trajectory of tactile localisation
in children with DCD. The remaining components of tactile function were comparable between children with and without
DCD, which supports previous research on tactile registration (Law et al., 2011) however contrasts with 2PD and
stereognosis results from earlier studies (Elbasan et al., 2012; Law et al., 2011; Schoemaker et al., 2001). Given that a multi-
dimensional and standardised tactile battery of registration and perception was used in this study, with specific
dermatomal locations, it is believed that this is a more accurate representation of tactile function in children with DCD.
Findings indicate that complex higher order processing in the form of spatial tactile perception may be the specific deficit
important in the DCD population.
To our knowledge, this is the first study to comprehensively examine the relationship between unilateral tactile and
upper limb motor function in children with DCD. Effective upper limb motor coordination requires concurrent use of
sensation and perception in multiple modalities (vision, proprioception and tactile) as well as motor control, muscle strength
and endurance (Blank et al., 2012; Johansson & Cole, 1992; Johansson & Flanagan, 2009; Maeland, 1992). Our results
demonstrate that tactile function, specifically spatial tactile perception, was a significant predictor of upper limb motor
performance. In fact, localisation (SPL) in the dominant hand accounted for 16% of the variability in MABC-2 manual
dexterity scores and 33% of the variability in the speed of everyday manual tasks (JTTHF). Considering the potential
contribution of all other sensory systems during manipulation as well as the impact of efferent motor deficits, this result
emphasises the significant role that spatial tactile perception plays in quality and speed of unimanual performance. This is
not surprising, since spatial tactile receptors densely populate the finger tips, overriding visual information after initial
contact to provide information about the object including shape, movement (friction) and breaking of contact between the
object and fingers, to calibrate and correct errors in grasp (Johansson & Flanagan, 2009). Poor tactile spatial perception may
therefore impact execution and feedback phases of goal-directed movement of the upper limb. Therefore, assessments of SPL
ability of the hands should be conducted in children with DCD who display upper limb motor difficulties.
Results of this study also demonstrate that tactile function has a substantial role in handwriting proficiency. Poor
handwriting proficiency has been shown to impact academic performance therefore needs to be a priority when assessing
children with DCD (Chang & Yu, 2010; Feder & Majnemer, 2007). The two critical outputs of handwriting are legibility and
speed. There is typically an inverse relationship between these elements, where increases in speed may result in reduced
legibility and legibility can be improved by reducing speed (Weintraub & Graham, 1998). Tactile perception has been
identified as a key determinant in these handwriting outputs in TD children, which is proposed to reflect the high level of
coordination the task requires (Feder & Majnemer, 2007; Yu et al., 2012). In children with DCD in our study, better
localisation (SPL) was also associated with better legibility of letters and numerals. This can be explained by research
demonstrating that tactile afferents are responsible for precise force calibration between the fingers and pen during writing
(Hsu et al., 2013; Johansson & Flanagan, 2009), which is critical for producing a legible script. Legibility of numerals was also
significantly associated with stereognosis including stereognosis of manual forms and common objects (p < 0.05).
Alternatively, registration was associated with an improvement in letters per minute for the composition task which
demonstrates that children who have better ability to initially detect a tactile stimulus are writing faster. Thus, it is clear that
underlying tactile registration and perception plays a significant role in the legibility and speed of handwriting and should
therefore be a priority when assessing children with DCD clinically.
Two-point discrimination was statistically associated with handwriting proficiency in this study, however closer
inspection of the data indicated that all children with DCD and TD scored within the clinically normal range for static 2PD
(3–5 mm) on the index finger and thumb (Auld et al., 2011). On clinimetric review, the smallest detectable change for static
2PD is reported between 0.8 for TD children to 1.7 for children with significant motor disorders (Auld, Boyd, et al., 2012; Auld,
Ware, et al., 2012). This indicates that in our study of 20 children with DCD and 16 children with TD, that there was not a clear
382 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383

separation between groups. Therefore, although a relationship between 2PD and handwriting was demonstrated
statistically, further research with a larger cohort is required to confirm if this finding is clinically relevant.
Our results suggest that stereognosis of children with DCD may play a lesser role in upper limb motor function compared
to children with brain injury (Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012; Sakzewski et al., 2010). The only relationship
identified was between manual form perception in the non-dominant hand and aiming and catching. This may be a chance
finding, or it may indicate that stereognosis, which is achieved through hand movement, may be subject to similar motor
problems as when catching a ball. However, it is also possible that the test stimuli were not difficult enough for this
population. Further refining of stereognosis assessments to emphasise speed and to introduce objects of greater novelty or
difficulty should be investigated to more clearly examine the role of stereognosis in children who display functional upper
limb motor difficulties.

4.1. Limitations and future directions

Although this study showed several significant findings, there are a few limitations and several future directions to
highlight. First, it appears that there was a ceiling effect on some outcome measures for children with DCD, including the
JTTHF and stereognosis. Further research is required to extend the difficulty of these tests and determine the level at which
children with DCD are challenged with these skills in functional tasks. Second, this study demonstrated significant
relationships between unilateral upper limb tactile and motor deficits in children with DCD, however more extended
examination in other populations has now demonstrated that bilateral tactile and motor relationships are somewhat
different and equally important to consider (Auld, Boyd, et al., 2012; Auld, Ware, et al., 2012). Thus, further research of
bilateral and multidermatomal sensory and motor function is warranted in the DCD population. Third, it is possible that
greater participant numbers may have lead to significant outcomes for some tactile predictors, in particular SPL in the
dominant hand (p = 0.06), which reached significance in the non-dominant hand (p = 0.04). Finally, future investigations may
benefit from exploring tactile function in the lower limbs. This study identified a significant association between poor SPL
and poor balance, which is not directly related, but may reflect that children with DCD who display upper limb tactile
perception deficits may also display these in the lower limb impacting their balance.

5. Conclusion

This study demonstrates that children with DCD are at risk for deficits in spatial tactile function in their hands with 50% of
children in our study performing below the normal range for single point localisation in their non-dominant hand and 30%
for their dominant hand. It was also shown that SPL is a major predictor of upper limb motor performance. This indicates that
errors in higher order processing in the form of spatial tactile perception may be contributing to the upper limb coordination
difficulties experienced by children with DCD. Therefore our recommendations are that clinicians perform spatial tactile
perception assessments for children with DCD who show difficulties with fine motor performance in order to provide a more
targeted treatment programme for motor difficulties.

Acknowledgements

We would like to thank: Nicole Haynes from Allsports Paediatric Physiotherapy for recruitment and assessment support;
Asad Khan for valuable statistical advice; and all the parents and children who participated in the study.

References

Amundson, S. (1995). Evaluation tool of children’s handwriting: ETCH examiner’s manual. Homer, Alaska: OT KIDS.
American Pyschiatric Association (APA) (2013). Diagnostic and statistical manual of mental disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing.
Auld, M. L., Boyd, R., Moseley, G., Ware, R., & Johnston, L. (2012). Impact of tactile dysfunction on upper-limb motor performance in children with unilateral
cerebral palsy. Archives of Physical Medicine and Rehabilitation, 93(4), 696–702.
Auld, M. L., Boyd, R. N., Moseley, G. L., & Johnston, L. M. (2011). Tactile assessment in children with cerebral palsy: A clinimetric review. Physical & Occupational
Therapy in Pediatrics, 31(4), 413–439.
Auld, M. L., Tan, X. Y., Marozza, A., & Johnston, L. M. (2014). inTOUCH: reproducibility of a new stereognosis battery. In Paper presented at the 7th Biennial Conference
of the Australasian Academy of Cerebral Palsy and Developmental Medicine, Hunter Valley, Australia.
Auld, M. L., Ware, R., Boyd, R., Moseley, G., & Johnston, L. (2012). Reproducibility of tactile assessments for children with unilateral cerebral palsy. Physical &
Occupational Therapy in Pediatrics, 32(2), 151–166.
Ayres, A. (1989). Sensory integration and praxis tests. Los Angeles: Western Psychological Services.
Bair, W. N., Barela, J. A., Whitall, J., Jeka, J. J., & Clark, J. E. (2011). Children with developmental coordination disorder benefit from using vision in combination with
touch information for quiet standing. Gait Posture, 34(2), 183–190.
Beery, K. (1997). Developmental test of visual-motor intergation (VMI) administration, scoring and teaching manual. Parsippany: Modern Curriculum Press.
Bell-Krotoski, J., & Tomancik, E. (1987). The repeatability of testing with Semmes-Weinstein monofilaments. The Journal of Hand Surgery (American ed.), 12(1),
155–161.
Blank, R., Smits-Engelsman, B., Polatajko, H., & Wilson, P. (2012). European Academy for Childhood Disability (EACD) recommendations on the definition,
diagnosis and intervention of developmental coordination disorder. Developmental Medicine & Child Neurology, 54(1), 54–93.
Burns, Y. (1992). NSMDA physiotherapy assessment for infants and young children. Brisbane, Australia: CopyRight.
Chang, S. H., & Yu, N. Y. (2010). Characterization of motor control in handwriting difficulties in children with or without developmental coordination disorder.
Developmental Medicine & Child Neurology, 52(3), 244–250.
 L.E. Cox et al. / Research in Developmental Disabilities 45–46 (2015) 373–383 383

Diekema, S. M., Deitz, J., & Amundson, S. J. (1998). Test–retest reliability of the evaluation tool of children’s handwriting-manuscript. The American Journal of
Occupational Therapy, 52(4), 248–255.
Duff, S., & Goyen, T. A. (2010). Reliability and validity of the evaluation tool of children’s handwriting-cursive (ETCH-C) using the general scoring criteria.
The American Journal of Occupational Therapy, 64(1), 37–46.
Elbasan, B., Kayihan, H., & Duzgun, I. (2012). Sensory integration and activities of daily living in children with developmental coordination disorder. Italian Journal
of Pediatrics, 38(1), 14.
Feder, K. P., & Majnemer, A. (2007). Handwriting development, competency, and intervention. Developmental Medicine & Child Neurology, 49(4), 312–317.
Gustafson, G. E., & Chen, X. (2002). Handedness. In N. J. Salkind (Ed.), Child development (p. 172). New York: Macmillan Reference USA.
Henderson, S. E., Sugden, D. A., & Barnett, A. L. (2007). Movement assessment battery for children-2. United Kingdom, London: Pearson Education.
Hsu, H. M., Lin, Y. C., Lin, W. J., Lin, C. J., Chao, Y. L., & Kuo, L. C. (2013). Quantification of handwriting performance: Development of a force acquisition pen for
measuring hand-grip and pen tip forces. Measurement: Journal of the International Measurement Confederation, 46(1), 506–513.
Jebsen, R., Taylor, N., Trieschmann, R., Trotter, M., & Howard, L. (1969). An objective and standard test of hand function. Archives of Physical Medicine and
Rehabilitation, 50(6), 311–319.
Johansson, R. S., & Cole, K. J. (1992). Sensory-motor coordination during grasping and manipulative actions. Current Opinion in Neurobiology, 2(6), 815–823.
Johansson, R. S., & Flanagan, J. R. (2009). Coding and use of tactile signals from the fingertips in object manipulation tasks. Nature Reviews Neuroscience, 10(5),
345–359.
Kaas, A., van de Ven, V., Reithler, J., & Goebel, R. (2013). Tactile perceptual learning: Learning curves and transfer to the contralateral finger. Experimental Brain
Research, 224(3), 477–488.
Klingels, K., De Cock, P., Molenaers, G., Desloovere, K., Huenaerts, C., Jaspers, E., et al. (2010). Upper limb motor and sensory impairments in children with
hemiplegic cerebral palsy. Can they be measured reliably? Disability and Rehabilitation, 32(5), 409–416.
Laszlo, J. I., Bairstow, P. J., Bartrip, J., & Rolfe, U. T. (1988). Clumsiness or perceptuo–motor dysfunction? Advances in Psychology, 55, 293–310.
Law, S.-H., Lo, S. K., Chow, S., & Cheing, G. L. Y. (2011). Grip force control is dependent on task constraints in children with and without developmental coordination
disorder. International Journal of Rehabilitation Research, 34(2), 93–99.
Mackinnon, S. E., Mackinnon, S. E., & Dellon, A. L. (1985). Two-point discrimination tester. The Journal of Hand Surgery, 10(6), 906–907.
Maeland, A. F. (1992). Handwriting and perceptual skills in clumsy, dsygraphic and normal children. Perceptual and Motor Skills, 75(3), 1207–1217.
Malloy-Miller, T. (1995). Handwriting error patterns of children with mild motor difficulties. Canadian Journal of Occupational Therapy, 62(5), 258–267.
McHale, K., & Cermak, S. A. (1992). Fine motor activities in elementary school: preliminary findings and provisional implications for children with fine motor
problems. The American Journal of Occupational Therapy, 46(10), 898–903.
Miller, L. T., Missiuna, C. A., Macnab, J. J., Malloy-Miller, T., & Polatajko, H. J. (2001). Clinical description of children with developmental coordination disorder.
The Canadian Journal of Occupational Therapy, 68(1), 5–15.
Mon-Williams, M., Tresilian, J. R., Bell, V. E., Coppard, V. L., Nixdorf, M., & Carson, R. G. (2005). The preparation of reach-to-grasp movements in adults, children, and
children with movement problems. The Quarterly Journal of Experimental Psychology, 58(7), 1249–1263.
Novak, C. B., Mackinnon, S. E., & Kelly, L. (1993). Correlation of two-point discrimination and hand function following median nerve injury. Annals of Plastic Surgery,
31(6), 495–498.
Oldfield, R. C. (1971). The assessment and analysis of handedness: The Edinburgh inventory. Neuropsychologia, 9(1), 97–113.
Polatajko, H., & Cantin, N. (2006). Developmental coordination disorder (Dyspraxia): An overview of the state of the art. Seminars Pediatric Neurology, 12, 250–258.
Rosenblum, S., & Livneh-Zirinski, M. (2008). Handwriting process and product characteristics of children diagnosed with developmental coordination disorder.
Human Movement Science, 27(2), 200–214.
Sakzewski, L., Ziviani, J., & Boyd, R. (2010). The relationship between unimanual capacity and bimanual performance in children with congenital hemiplegia.
Developmental Medicine & Child Neurology, 52(9), 811–816.
Schneck, C. M. (1991). Comparison of pencil-grip patterns in first graders with good and poor writing skills. American Journal of Occupational Therapy, 45(8),
701–706.
Schoemaker, M., Wees, V., Flapper, B., Verheij-Jansen, N., Scholten Jaegers, S., & Geuze, R. (2001). Perceptual skills of children with developmental coordination
disorder. Human Movement Science, 20, 111–133.
Sigmundsson, H., Hansen, P. C., & Talcott, J. B. (2003). Do ‘clumsy’ children have visual deficits. Behavioural Brain Research, 139(1), 123–129.
Smits-Engelsman, B. C. M., Niemeijer, A. S., & Van Galen, G. P. (2001). Fine motor deficiencies in children diagnosed as DCD based on poor grapho-motor ability.
Human Movement Science, 20(1), 161–182.
Smyth, T. R. (1994). Clumsiness in children: A defect of kinaesthetic perception? Child: Care, Health and Development, 20(1), 27–36.
StataCorp (2013). Stata Statistical Software. College Station, TX, USA: StataCorp.
Tsai, C. L., Wilson, P. H., & Wu, S. K. (2008). Role of visual–perceptual skills (non-motor) in children with developmental coordination disorder. Human Movement
Science, 27(4), 649–664.
Watter, P. (1996). Physiotherapy management of children–minor coordination dysfunction. In Y. Burns & J. MacDonald (Eds.), Physiotherapy and the growing child
(pp. 415–436). London: WB Saunders Co Ltd.
Weintraub, N., & Graham, S. (1998). Writing legibly and quickly: A study of children’s ability to adjust their handwriting to meet common classroom demands.
Learning Disabilies Research, 13(3), 146–152.
Wilmut, K., Byrne, M., & Barnett, A. L. (2013). Reaching to throw compared to reaching to place: a comparison across individuals with and without Developmental
Coordination Disorder. Research in Developmental Disabilities, 34(1), 174–182.
Yu, T. Y., Hinojosa, J., Howe, T. H., & Voelbel, G. (2012). Contribution of tactile and kinesthetic perceptions to handwriting in Taiwanese children in first and second
grade. Occupation, Participation, and Health, 32(3), 87–89.