R E V I E W A R T I C L E

Dual-Task Methodology:
Applications in Studies of
Cognitive and Motor Performance
in Adults and Children
Hsiang-Ju Huang, BS, PT and Vicki Stemmons Mercer, PhD, PT
Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC

Purpose: The purpose of this article is to review the literature related to the application of dual-task method-
ology in adults and children, particularly in the areas of gait and postural stability. Summary of Key Points: The
interaction between cognitive factors and motor performance recently has received considerable attention in
physical therapy research. Researchers often use dual-task methodology to investigate the attentional de-
mands of motor tasks or the effects of concurrent tasks on motor performance. The attentional demands of a
task and the interference effects of concurrent tasks are influenced by a number of factors, including the
performer’s age, level of skill, and the nature of the tasks involved. Even highly practiced activities, such as
walking and postural control, are attention-demanding, especially in individuals with impairments.
Conclusions: An understanding of how attentional demands and other cognitive factors influence motor
performance may be helpful to physical therapists in structuring intervention activities and in identifying
children who have particular difficulty under dual-task conditions. By modifying both cognitive and motor task
demands, therapists can tailor their interventions to provide appropriate challenges for children at different
skill levels. (Pediatr Phys Ther 2001;13:133–140) Key words: child, adult, attention, motor skills, psychomotor
performance

INTRODUCTION background noise, obstacles, and distracting visual and au-

Researchers suggest that improved performance of
language, social, and behavioral skills in clinical settings
does not necessarily transfer to performance during daily
activities in other settings.1–3 This lack of generalization
also may hold true for the types of motor skills that are the
focus of physical therapy intervention.4 – 6 A child with ce-
rebral palsy (CP) may walk successfully in the clinical set-
ting, for example, but have difficulty walking at school or
on the playground. Differences in the cognitive and per-
ceptual demands of different settings may contribute to the
lack of carryover. Most environments are characterized by
0898-5669/01/1303-0133
Pediatric Physical Therapy
Copyright © 2001 Lippincott Williams & Wilkins, Inc.
Address correspondence to: Dr. Vicki Stemmons Mercer, Division of
Physical Therapy, Department of Allied Health Sciences, CB# 7135, Med-
ical School Wing E, University of North Carolina at Chapel Hill, NC
27599-7135. Email: vmercer@med.unc.edu
ditory stimuli.5 In addition, children may encounter situa-
tions in their everyday lives in which they must perform
cognitive and motor tasks simultaneously. Because motor
performance is the result of an interaction among cogni-
tive, perceptual, mechanical, and neurologic mechanisms,7
the role of cognitive factors should be considered in phys-
ical therapy assessment and intervention.5– 8 Cognitive fac-
tors that may be important for motor performance include
arousal, attention, memory, motivation, and judgement.9
In this article, the role of attention as it relates to motor
performance is considered.
An important research paradigm for the study of at-
tentional processes is the dual-task paradigm.10,11 In dual-
task paradigms, individuals are asked to perform two tasks
simultaneously. Dual-task paradigms typically are used for
two different purposes.10 One is to investigate the atten-
tional demands of a motor task and the other is to examine
the effects of concurrent cognitive or motor tasks on motor
performance. The latter is sometimes referred to as a di-
vided attention or “time-sharing” paradigm. Researchers
have used both types of dual-task methodology to examine

Pediatric Physical Therapy Dual-Task Methodology 133

the influence of attention on gait and balance among vari-
ous age groups, subject populations, and types of concur-
rent tasks.12–23
Most dual-task studies of children have been focused
on developmental differences in specific cognitive
skills.24 –28 Although the development of cognitive pro-
cesses is of interest to physical therapists, research related
to the effects of concurrent cognitive or motor tasks on
motor performance may be of even greater relevance. Re-
sults of studies using the divided attention paradigm pro-
vide insight into the changes in performance that may be
expected when children are required to do two things at
once. Increased understanding of the effects of divided at-
tention on motor performance may assist physical thera-
pists in incorporating attentional factors into their exami-
nation and intervention techniques.
This review of literature begins with an overview of
dual-task methodology, including background informa-
tion on its use in research with adults. This overview is
followed by a description of the application of dual-task
methodology in pediatrics, focusing on effects of concur-
rent cognitive tasks on children’s motor performance. Fi-
nally, clinical implications and suggestions for future stud-
ies are discussed.
DUAL-TASK METHODOLOGY
Attentional Demands of Specific Tasks
As noted above, dual-task methodology can be used in
research to assess the attentional demands of a specific
motor task, termed the primary task. This primary task is
the main focus of this type of study. The assumptions of
this paradigm are that central processing capacity is limited
and that the capacity must be divided between the two
concurrent tasks in various ways, depending on the strat-
egy the subject chooses. Performance of the primary task is
assumed to require some proportion of the limited process-
ing capacity. The more demanding the primary task, the
greater the proportion of the performer’s limited process-
ing capacity that must be allocated to maintain an accept-
able level of performance. Secondary task performance is
considered a direct reflection of the absolute quantity of
residual processing capacity.10 In Figure 1, for example,
Fig. 1. Schematic representation of the attentional demands of
two different primary tasks, A and B. Less residual processing
capacity is available during the performance of task B.
134 Huang and Stemmons Mercer
primary task B requires a larger proportion of the process-
ing capacity than primary task A. Consequently, secondary
task performance should be worse when the secondary task
is paired with task B than with task A.
When the dual-task paradigm is used to assess atten-
tional demands, individuals usually are instructed to main-
tain a given level of performance on the primary task under
dual-task conditions. Provided that primary task perfor-
mance is maintained at baseline level under dual-task con-
ditions, any change in the performance of the secondary
task relative to baseline is taken as an indicator of the at-
tentional demands of the primary task. When the demands
of the concurrent tasks exceed the available processing
capacity, deterioration in performance of one or both tasks
is expected.10
Researchers have raised several concerns related to
the use of this paradigm.10,26 One is the potential for sub-
jects to sacrifice primary task performance to execute the
secondary task. In this case, the attention demand of the
primary task cannot be estimated. Although researchers
attempt to minimize this problem by instructing subjects
to focus on the primary task, subjects may switch attention
between tasks or use other strategies that may not be easily
identified or assessed.
Another concern relates to the assumption of a fixed
or limited central processing capacity. Some authors have
argued that the capacity for attention can change with
changes in task requirements,29 whereas others have sug-
gested that central processing depends on multiple re-
sources rather than on a single resource.30 Different inde-
pendent resource pools have been postulated as a function
of different modalities of stimulus input and different re-
sponse modes.26 According to multiple resource theories,
dual-task costs should occur only to the extent that two
tasks tap into the same resources.26,30
Kahneman29 noted that, for certain combinations of
tasks, interference may be purely structural in nature.
Structural interference is considered to arise whenever
concurrent tasks compete for identical input or output
pathways. For example, structural interference would be
likely to occur if subjects were asked to produce reaction-
time responses to visual stimuli while simultaneously us-
ing a visual target to decrease their postural sway in stand-
ing. In the absence of any apparent structural effects,
interference may be attributed to capacity effects. Capacity
interference is thought to reflect a true overload of central
processing capacity.
Researchers have used the dual-task paradigm to
study the attentional demands of maintaining an upright
posture. Lajoie et al16 examined the attentional demands of
sitting, standing, and walking in young adults between the
ages of 20 and 30 years. Subjects performed four tasks: 1) a
baseline or control sitting condition, 2) standing upright
with a broad base of support, 3) standing upright with a
narrow base of support, and 4) walking at the subject’s
preferred speed. The secondary task was an auditory reac-
tion-time task that required a verbal response and thus was
Pediatric Physical Therapy
unlikely to produce structural interference with the pos-
tural tasks. The researchers measured changes in reaction
times under the dual-task conditions as indicators of the
attentional demands of the standing and walking tasks.
Results of the Lajoie et al16 experiment are illustrated
in Figure 2. Reaction times were shorter for the sitting task
than for the standing and walking tasks, and reaction times
for both standing tasks were shorter than for the walking
task. Reaction times also were shorter during double-sup-
port than during single-support phases of walking. No dif-
ferences were found between reaction times during stand-
ing with a broad base of support and standing with a
narrow base of support.
Lajoie et al16 interpreted their results as indicating that
attentional demands increase as the balance requirements
of a task increase. Although they provided evidence that
the addition of the probe reaction-time task did not affect
the gait pattern of their subjects, they had no baseline (sin-
gle-task) measurements of performance on the standing
tasks. Consequently, we cannot assume that performance
of these postural tasks was unchanged from baseline and
that the differences in reaction times under dual-task con-
ditions were truly indicative of differences in the atten-
tional demands of the tasks.
Wright and Kemp22 and Bardy and Laurent31 studied
the attentional demands of walking under various environ-
mental conditions in adults. In both studies, the research-
ers instructed the subjects to give priority to the walking
task. Wright and Kemp22 compared the attentional de-
mands of walking with a standard walker and a rolling
walker. Subjects performed a secondary reaction-time task
that included an auditory stimulus and a vocal response.
The reaction time data indicated that walking with a stan-
dard walker was more attention-demanding than walking
with a rolling walker or walking without an assistive de-
vice. One limitation of this study was that the subjects were
young- to middle-aged adults with no apparent physical or
cognitive dysfunction, thus preventing generalization of
Fig. 2. Diagrammatic representation of the results of the study by
Lajoie et al.16 RTsit ⫽ auditory reaction time during sitting; RTwb ⫽
auditory reaction time during standing with a wide base of sup-
port; RTnb ⫽ auditory reaction time during standing with a narrow
base of support; RTwalk ⫽ auditory reaction time during walking.
Pediatric Physical Therapy
the findings to patient populations. Another limitation was
that a 6.1-meter line was taped to the floor and subjects
were instructed to either place one foot on each side of the
line or place the right foot on the line while proceeding
along the walkway. These instructions may well have al-
tered the subjects’ natural gait patterns and the attentional
demands of the walking tasks.
Bardy and Laurent31 reported that differences in the
size of a visual target affected the cognitive processing de-
mands of walking in adults. Walking toward a small target
resulted in a larger increase in reaction time on the second-
ary task than walking toward a large target. In addition, the
reaction times increased sooner for the smaller target. In-
terpretation of these results is complicated by the finding
that the primary (walking) task performance was altered by
the addition of the secondary task. Subjects began deceler-
ating earlier when approaching the small target under du-
al-task as compared with single-task conditions. Conse-
quently, we cannot conclude with certainty that the larger
and earlier increases in reaction time when walking toward
the small target represented greater attentional demands
for this task compared with walking toward a large target.
In general, studies of the attentional demands of var-
ious motor tasks have been limited because of small sample
sizes (n ⫽ 6, 10, and 11 for Lajoie et al,16 Wright and
Kemp,22 and Bardy and Laurent,31 respectively) and by the
assumption of a single, fixed attentional capacity. In the
final analysis, knowledge of the attentional demands of
particular tasks may not be as important to physical thera-
pists as information about patterns of interference between
different tasks and the strategies that subjects use under
dual-task conditions. The divided attention or time-shar-
ing paradigm described below is used to examine these
interference effects.
Effects of Divided Attention on Motor
Performance
When dual-task methodology is used to investigate
the effects of divided attention, subjects typically are in-
structed to give equal priority to primary and secondary
task performance. Several researchers have chosen pos-
tural control tasks as primary tasks.18,32–34 Maylor and
Wing18 investigated the interference between five different
cognitive secondary tasks and postural stability in older
and younger adults. The five cognitive tasks were selected
according to the involvement of a working memory com-
ponent: random digit generation, Brooks’ spatial memory
task,35 backward digit recall, silent counting, and counting
backward by threes. Age differences in postural stability
were significantly increased under dual-task compared
with single-task conditions for Brooks’ spatial memory task
and backward digit recall. Both of these tasks theoretically
involve use of the visuospatial sketchpad, described by
Baddeley36 as a component of working memory responsible
for structuring and manipulating visuospatial images.
Maylor and Wing18 concluded that age differences in pos-
tural stability are increased only when the visuospatial
Dual-Task Methodology 135
sketchpad is used, not simply when overall attentional de-
mands increase.
Along similar lines, Shumway-Cook and Wollacott33
and Shumway-Cook et al34 investigated the effects of cog-
nitive tasks on postural stability in young vs older adults.
In the study by Shumway-Cook and Woollacott,33 subjects
performed a choice reaction-time task while maintaining
quiet standing under six different sensory conditions that
manipulated the availability of accurate visual and somato-
sensory cues. The reaction-time task required subjects to
verbally identify an auditory tone as being “high” or “low.”
Addition of the reaction-time task did not affect postural
stability in any of the sensory conditions in young adults,
but resulted in decreased stability when both visual and
somatosensory cues were removed in older adults with no
known balance impairments. Older adults with a history of
imbalance and falls exhibited decreased postural stability
with the addition of the reaction-time task in all six sensory
conditions. Although the researchers concluded that there
is an age-related increase in attentional demands for pos-
tural control with a decrease in available sensory informa-
tion, this interpretation is open to debate. The results also
could be interpreted as simply reflecting an age-related
difference in the pattern of interference of the specific re-
action time and postural tasks investigated in the study.
Shumway-Cook et al34 used a language processing
task and a visual spatial orientation task to produce
changes in attention during performance of standing tasks
on firm vs compliant surfaces. The three groups studied
were young adults, older adults without a history of falls,
and older adults with a history of falls. Performance decre-
ments were found in the postural stability measures rather
than the cognitive measures for all three groups. The addi-
tion of either cognitive task to the single-task standing
condition produced a significant difference in stability
among the three groups, with the older adults with a his-
tory of falls exhibiting the most instability and the young
adults the least.
Contrary to the expectations of the researchers and
the results of Maylor and Wing,18 interference effects in the
study by Shumway-Cook et al34 were larger for the lan-
guage-processing task than the visual spatial orientation
task. The researchers suggested that one explanation for
the discrepant findings was that their language-processing
task was a sentence completion task that was presented
visually, and therefore may have placed some demands on
visual processing pathways. Another explanation is that
the language-processing task may have been more difficult
than the spatial orientation task, creating a greater cogni-
tive load. Evidence from other studies32,37 supports the ex-
istence of interference effects resulting from competition
for visual processing pathways when visual and postural
tasks are combined.
Geurts et al32 investigated the level of automaticity of
postural control ability in individuals with lower limb am-
putation and an age-matched control group. Their primary
interest was in the effects of a concurrent cognitive task,
the modified Stroop test,38,39 on postural stability in stand-
136 Huang and Stemmons Mercer
ing. In the modified Stroop test, subjects were presented
with color names printed in different colors of ink. The
color of the ink was always inconsistent with the color
name (eg, the word “red” was printed in blue ink). Subjects
were instructed to ignore the color name and verbally re-
port the color of the ink. Subjects with amputation were
tested before and after their participation in a rehabilitation
program. Although body sway did not change significantly
after rehabilitation when measured under single-task con-
ditions, significant changes were observed under dual-task
conditions. The interference effects of the Stroop test on
postural control were lower after rehabilitation in subjects
with amputation, although their body sway remained
greater than that of control group subjects.
The finding by Geurts et al32 that only the dual-task
performance improved during the rehabilitation process
suggests that imposition of secondary cognitive tasks may
be one method of detecting changes in primary task per-
formance that would otherwise go unnoticed. This sugges-
tion is consistent with the work by Shumway-Cook and
colleagues33,34 with older adults with a history of imbalance
and falls, who demonstrated much greater deficits under
dual-task than single-task conditions. Geurts et al32 stated
that the interference effects in their study might have arisen
from general competition for limited resources or from
more specific interference related to the visual processing
demands of performing the Stroop test and the standing
task simultaneously. They speculated that the subjects
with lower limb amputation might have decreased their
dependency on visual information during the rehabilita-
tion process, thereby reducing interference in visual pro-
cessing pathways under dual-task conditions.
Research on the effects of divided attention on gait is
more limited than that on the effects of divided attention
on postural stability in standing. Ebersbach et al13 investi-
gated the influence of different concurrent tasks on gait in
10 healthy subjects between the ages of 25 and 42 years.
Concurrent tasks included a cognitive task (digit span for-
ward), a buttoning task, a finger-tapping task, and a task in
which digit span was combined with buttoning. Subjects
were instructed to concentrate on the concurrent task
rather than on gait performance under dual-task condi-
tions. Interference effects were observed for digit span for-
ward, the only concurrent task for which changes between
single- and dual-task conditions were quantified. Gait per-
formance was assessed for changes in stride time and dou-
ble-support time. Stride time differed between single- and
dual-task conditions for the finger-tapping task only, a
finding that the researchers attributed to structural inter-
ference at the subcortical level for competing rhythmic
output. This explanation makes sense in that the require-
ments for producing fast finger tapping (frequency of five
Hz or higher) were likely to “pace” or entrain the walking
performance and produce a decrease in stride time. Dou-
ble-support time differed between single- and dual-task
conditions only in the situation in which digit span was
combined with buttoning.
Interpretation of the results of the study by Ebersbach
Pediatric Physical Therapy
et al13 is complicated by several methodological issues. In-
structions to the subjects were not consistent with those
recommended for divided attention paradigms.10 In addi-
tion, changes in concurrent task performance were mea-
sured for the digit span task only, and this task was not
administered consistently under single- and dual-task con-
ditions. Under dual-task conditions, subjects were re-
quired to listen to and retain the digits while walking, but
were not required to repeat the digits until after completion
of each walking pass. However, a delay between presenta-
tion of the digits and request for digit recall was not present
under single-task conditions. These methodological issues
make interpretation of the findings related to changes in
double-support time particularly problematic. Because the
authors did not report changes in double-support time rel-
ative to overall changes in gait speed, their suggestion that
the increase in double-support time was related to the at-
tentional demands of balance control during gait seems
unjustified. With the addition of two concurrent tasks, the
attentional demands were probably quite high, but these
may not have been specifically related to balance control.
In summary, dual-task methodology is often used to
examine the role of cognition in motor performance from
two perspectives. One is to assess the attentional demands
of motor skills; the other is to investigate the effects of
divided attention on motor skills. Some aspects of even
highly practiced tasks such as postural control and gait
require attention. Interference effects differ for different
concurrent cognitive or motor tasks, with interference
likely to occur whenever concurrent tasks compete for the
same resources. Imposition of concurrent cognitive or mo-
tor tasks may be one method of detecting changes in bal-
ance or gait performance that would otherwise go
unnoticed.
APPLICATION OF DUAL-TASK METHODOLOGY IN
CHILDREN
Attentional Demands of Specific Tasks
The application of dual-task methodology in children
frequently has involved investigation of the attentional de-
mands of various cognitive tasks. Researchers have focused
on age differences in mental resource demands of cognitive
skills such as memorization, rehearsal, and reasoning abil-
ity.24 –28 These studies are important to physical therapists
in understanding how age-related differences in cognitive
abilities may influence a child’s motor performance or a
child’s ability to combine cognitive and motor tasks. As
with the research on attentional demands in adults, this
research is based on the assumption of a limited processing
capacity. The magnitude of decline in secondary task per-
formance from single- to dual-task conditions is presumed
to index the resource demands of the primary cognitive
task.
Several researchers investigated the mental demands of
cognitive skills by examining the amount of interference in
finger-tapping or reaction-time performance produced by pri-
mary cognitive tasks in school-aged children.24,25,28,40 – 42 In
Pediatric Physical Therapy
many of these studies, older children exhibited both superior
performance on the primary task and less secondary task in-
terference than younger children.40,41 The age differences in
secondary task interference presumably would have been
even larger if the researchers had attempted to equate primary
task performance across age. In studies in which performance
on the primary task of interest was equal across age groups,
the amount of interference in secondary task performance
produced by the primary task declined with age.25,42 The
smaller decrement in secondary task performance under du-
al-task conditions in older compared to younger children may
be because of greater cognitive resources or more efficient
allocation of these resources in older children. Children also
improve in their ability to use cognitive strategies as they get
older, employing strategies spontaneously and with increas-
ing effectiveness.24,25,40,42
Effects of Divided Attention on Motor
Performance
Most studies of the effects of attention on motor skill
performance in children have used some version of the
divided attention or time-sharing paradigm. Researchers
have focused on developmental changes in the ability to
simultaneously perform various cognitive and motor tasks.
In some studies, such as studies of verbal-manual time
sharing, both concurrent tasks have involved a motor com-
ponent. For example, children have been asked to recite
tongue twisters or animal names while concurrently per-
forming manual skills such as finger tapping.43– 45 In other
studies, researchers have used cognitive tasks in combina-
tion with more complex motor skills.19,21
Studies of verbal-manual time sharing in children
have consistently revealed asymmetric interference ef-
fects.43– 46 Speaking produces greater interference with
right-hand finger tapping than with left-hand finger tap-
ping in right-handed children. The degree of asymmetry
remains constant across the age range of three to 12 years.44
These findings support the “functional distance” principle
of cerebral organization described by Kinsbourne and
Hicks.47 This principle states that the amount of interfer-
ence between two incongruous activities varies inversely
with the functional distance between their respective cere-
bral control centers. Because speech production is lateral-
ized to the left hemisphere in right-handers, the functional
distance model predicts greater interference with motor
performance of the right hand. According to Kinsbourne
and colleagues,47,48 the effects should be more pronounced
in children compared to adults and in younger children
compared to older children because of restricted cerebral
space earlier in development. Results of recent investiga-
tions with adult subjects have failed to fully support the
predictions of the functional distance model, however.49,50
Instead, these studies have revealed a large number of vari-
ables, such as hand differences in single-task performance,
that may confound the effects of cerebral organization on
dual-task performance.
As with the studies of developmental changes in cog-
nition, research on motor skill performance suggests that
Dual-Task Methodology 137
older children exhibit less interference under dual-task
conditions than younger children.43,44,49 Presumably, the
motor tasks become more automated and under more sub-
conscious control with increasing age or practice.11,19
Smith and Chamberlin19 examined the effect of concurrent
tasks on soccer performance for subjects with different lev-
els of expertise. Fourteen 11- to 19-year-old soccer players
were categorized as novice, intermediate, or expert players.
The primary task was rapid running of a slalom course and
the secondary tasks were dribbling a soccer ball and geo-
metric shape identification. The novice group showed dis-
proportionate decreases in running speed compared to the
other two groups when both secondary tasks were per-
formed in combination with the primary running task.
Within each group, the addition of each secondary task
resulted in slowing of primary task performance. The au-
thors concluded that the addition of cognitively demand-
ing secondary tasks had a disturbing effect on primary task
performance across all levels of expertise, but the ampli-
tude of the effect decreased as the level of expertise in-
creased. This result supports the idea that motor task per-
formance may become more automated with increased
practice and experience.
Whitall21 investigated developmental differences in
the effects of concurrent cognitive tasks on two locomotor
skills, running and galloping. Forty children (three to 10
years of age) and adults (18 to 34 years of age) completed
the study. Two verbal secondary tasks, singing and letter-
memorization, were used. The results indicated that coor-
dination variables, such as temporal phasing (step time
divided by stride time) and amplitude phasing (step length
divided by stride length), were unaffected by the addition
of a cognitive task regardless of the subject’s age. With
regard to control variables such as speed, step time, and
step length, subjects in all age groups tended to decrease
their step-lengths when attempting to execute two tasks
simultaneously. The amount of interference in perfor-
mance of the control variables was age-related and task-
related. The letter-memorization task caused greater ef-
fects on locomotor skills than singing, and the effect was
greater in running than galloping for the younger age
group.
Although characterizing her study as “time-sharing”
in the title and employing time-sharing methodology,
Whitall21 interpreted her results in terms of the attentional
demands of coordination and control variables in the two
locomotor skills. She suggested that the interlimb coordi-
nation variables were operating at an automatized level,
with the phasing pattern in place at a very early age (ap-
proximately three years). She noted that even the more
complicated, less practiced, asymmetrical phasing pattern
of galloping was unaffected by the imposition of the sec-
ondary tasks. In contrast to the expectations derived from
other studies, this result implies that only certain locomo-
tor performance variables, such as gait speed, step length,
and step time, become more automated and thus less atten-
tion-demanding with additional practice. The basic phase
relationships that distinguish different locomotor skills
138 Huang and Stemmons Mercer
may not be susceptible to interference effects in typically
developing children. Interestingly, Whitall21 did not find
any evidence that the singing rhythm entrained the gallop
to a new phasing pattern. She concluded that either no
entrainment took place or that the rhythmic pattern of
galloping was dominant, so that the singing entrained to
the galloping. The finding that singing slowed when paired
with galloping supported the latter possibility.
In addition to investigating developmental changes in
time-sharing performance in typically developing children,
researchers have used dual task methodology to examine
the automaticity of balance skills in children with dyslex-
ia.14,23 The primary interest in these studies was whether
children with dyslexia were significantly impaired in bal-
ance skills under dual-task compared with single-task con-
ditions. If balance skills were unaffected by performance of
concurrent tasks, then the skills would be considered au-
tomatic. Fawcett and Nicolson14 selected two primary task
conditions, standing on a balance beam with one foot and
with both feet. Two groups of subjects with dyslexia (mean
age of 11 and 15 years) and age-matched children with
typical development participated in the study. Perfor-
mance of the primary balance task was examined with and
without concurrent secondary tasks of counting or per-
forming a choice reaction time task. The secondary tasks
were “calibrated” to ensure a comparable level of perfor-
mance for the subjects with dyslexia and the comparison
group at baseline (ie, under single-task conditions). The
results showed that children with dyslexia were signifi-
cantly impaired in both balance and secondary task perfor-
mance under the dual-task condition compared with the
single-task condition, while typically developing children
showed no significant changes in either balance or second-
ary task performance from single- to dual-task conditions.
The researchers concluded that complex skills, such as
balance, are not automatized in children with dyslexia.
Similar results were reported by Yap and van der
Leij.23 In this study, 14 subjects with dyslexia (mean age of
10 years) and age-matched comparison group subjects
were asked to balance on one foot as the primary task and
to perform an auditory-choice reaction time task as the
secondary task. Children were instructed to give priority to
the secondary task. In the single-task condition, balance
performance of the children with dyslexia was not signifi-
cantly different from that of children in the comparison
group. However, children with dyslexia showed more bal-
ance errors, including minor foot movement or wobble, in
the dual-task condition than the single task condition,
while children in the comparison group did not.
Findings in the studies by Smith and Chamberlin,19
Whitall,21 Fawcett and Nicolson,14 and Yap and van der
Leij23 all were interpreted in terms of the automation of
motor performance. Automation is a decrease with practice
or development in the quantity of resources needed to at-
tain a given level of performance.51 According to Wickens
and Benel,51 automation is a characteristic of the specific
task as performed by the learner, and is distinct from more
Pediatric Physical Therapy
general time-sharing skills. Time-sharing skills are capabil-
ities or strategies that may affect dual-task performance,
such as attention switching, resource allocation, and infor-
mation sampling.51 Changes in these time-sharing skills,
rather than in the level of automation of primary task per-
formance, may at least partially account for the effects ob-
served in the studies described above.
In summary, studies of motor performance in chil-
dren, like those in adults, indicate interference effects with
the imposition of secondary tasks. Older children show
less interference than younger children, possibly because
of increased automation of motor performance or im-
proved time-sharing skills with maturation, practice, and
experience. Certain aspects of motor skills may be more
affected by secondary tasks than others. Temporal-distance
variables of gait, for example, appear more susceptible to
interference effects than interlimb coordination variables.
Consequently, changes in temporal-distance variables
from single- to dual-task conditions may be good indica-
tors of the degree of automaticity of motor performance in
children and adults.
CLINICAL IMPLICATIONS AND CONCLUSIONS
Knowledge derived from the dual-task literature can
be useful for pediatric physical therapists in several ways.
Increased understanding of the attentional demands of dif-
ferent cognitive and motor tasks should enable physical
therapists to make more informed decisions about how
they structure evaluation and intervention activities. Ther-
apists can be more cognizant of the demands they are plac-
ing on clients when they provide instructions, demonstra-
tions, or simply conversation that must be processed at the
same time as on-going motor performance. The increased
attentional demands of walking with various assistive de-
vices can also be taken into consideration.
The divided attention or time-sharing paradigm is es-
pecially relevant to children’s daily activities. Children fre-
quently encounter situations involving simultaneous per-
formance of two tasks, such as responding to verbal
instructions or manipulating an object while walking. By
adding concurrent cognitive or motor tasks during clinical
examinations and measuring changes in simple temporal
or distance variables, therapists may be able to determine
children’s abilities to perform motor tasks “automatically”
or, at least, to divide attention between tasks. Evaluation of
performance under dual-task conditions may reveal subtle
deficits that would otherwise go unnoticed.
If therapists have information about how concurrent
cognitive tasks influence motor performance, they may be
able to design more effective interventions by selecting mo-
tor tasks, structuring the environment, and providing in-
structions and feedback in a manner that is more consistent
with a child’s abilities. Children who are performing at a
high level may benefit from the challenge afforded by the
imposition of secondary tasks, while those who have diffi-
culty under dual-task conditions may need a quiet environ-
ment and very limited concurrent feedback. Perhaps as a
Pediatric Physical Therapy
child’s motor skills improve, concurrent tasks of increasing
difficulty can be systematically imposed.
Results of dual-task studies support the important
role of cognitive processing in motor performance and may
raise physical therapists’ awareness of the influence of cog-
nitive factors on motor control in clinical assessment and
intervention. Although this review has been limited to at-
tentional factors, other aspects of cognitive processing play
an important role as well. Additional research is needed
about the motor performance effects of different concur-
rent tasks in children who are developing typically and in
children with disabilities.
REFERENCES
1. Du Paul GS, Eckert TL. The effects of social skills curricula: now you
see them, now you don’t. Sch Psychol Q. 1994;2:113–132.
2. Handleman JS. Transfer of verbal responses across instructional set-
tings by autistic-type children. J Speech Hear Disord. 1981;46:69 –76.
3. House AE, Stambaugh EE. Transfer of therapeutic effects from insti-
tution to home: faith, hope, and behavior modification. Fam Process.
1979;18(1):87–93.
4. Singer RN, Chen D. A classification scheme for cognitive strategies:
implications for learning and teaching psychomotor skills. Res Q
Exerc Sport. 1994;65:143–151.
5. Mulder T, Pauwels J, Nienhuis B. Motor recovery following stroke:
towards a disability-orientated assessment of motor dysfunctions. In:
Harrison M, ed. Physiotherapy in Stroke Management. Edinburgh:
Churchill Livingstone; 1995: 275–282.
6. Mulder T. Current ideas on motor control and learning: implications
for therapy. In: Illis L, ed. Spinal Cord Dysfunction: Intervention and
Treatment. New York: Oxford University Press; 1992:187–209.
7. Campbell SK. The child’s development of functional movement. In:
Campbell SK, ed. Physical Therapy for Children. Philadelphia: WB
Saunders; 1994:3–37.
8. Mulder T, Geurts S. The assessment of motor dysfunctions: prelimi-
naries to a disability-oriented approach. Hum Mov Sci. 1991;10:565–
574.
9. Shumway-Cook A, Woollacott MH. Motor Control: Theory and Prac-
tical Applications. Baltimore, Md: Williams & Wilkins; 1995;216 –
217.
10. Abernethy B. Dual-task methodology and motor skills research: some
applications and methodological constraints. J Hum Mov Stud. 1988;
14:101–132.
11. Schmidt RA, Lee TD. Motor Control and Learning. 3rd ed. Champaign,
Ill: Human Kinetics; 1998.
12. Camicioli R, Howieson D, Lehman S. Talking while walking: the
effect of a dual task in aging and Alzheimer’s disease. Neurology.
1997;48:955–958.
13. Ebersbach G, Dimitrijevic MR, Porwe W. Influence of concurrent
tasks on gait: a dual-task approach. Percept Mot Skills. 1995;81:107–
113.
14. Fawcett A, Nicolson R. Automatisation deficits in balance for dyslexic
children. Percept Mot Skills. 1992;75:507–529.
15. Geurts ACH, Mulder TW. Reorganisation of postural control follow-
ing lower limb amputation: theoretical considerations and implica-
tion for rehabilitation. Physiother Theory Pract. 1992;8:145–157.
16. Lajoie Y, Teasdale N, Bard C. Attentional demands for static and
dynamic equilibrium. Exp Brain Res. 1993;97:139 –144.
17. Lajoie Y, Teasdale N, Bard C, et al. Upright standing and gait: are
there changes in attentional requirements related to normal aging?
Exp Aging Res. 1996;22:185–198.
18. Maylor EA, Wing AM. Age differences in postural stability are in-
creased by additional cognitive demands. J Gerontol. 1996;51B:P143–
P154.
Dual-Task Methodology 139
19. Smith M, Chamberlin C. Effect of adding cognitively demanding
tasks on soccer skill performance. Percept Mot Skills. 1992;75:955–
961.
20. Teasdale N, Bard C, LaRue J, et al. On the cognitive penetrability of
postural control. Exp Aging Res. 1993;19:1–13.
21. Whitall J. The developmental effect of concurrent cognitive and lo-
comotor skills: time-sharing from a dynamic perspective. J Exp Child
Psychol. 1991;51:245–266.
22. Wright D, Kemp T. The dual-task methodology and assessing the
attentional demands of ambulation with walking devices. Phys Ther.
1992;72:306 –315.
23. Yap RL, van der Leij A. Testing the automatization deficit hypothesis
of dyslexia via a dual-task paradigm. J Learn Disab. 1994;27:660 –
665.
24. Bjorklund D, Harnishfeger K. Developmental differences in the men-
tal effort requirements for the use of an organizational strategy in free
recall. J Exp Child Psychol. 1987;44:109 –125.
25. Guttentag RE. The mental effort requirement of cumulative rehears-
al: a developmental study. J Exp Child Psychol. 1984;37:92–106.
26. Guttentag RE. Age differences in dual-task performance: procedures,
assumptions, and results. Dev Rev. 1989;9:146 –170.
27. Halford G, Maybery M, Bain J. Capacity limitation in children’s rea-
soning: a dual-task approach. Child Dev. 1986;57:616 – 627.
28. Miller P, Seier W, Probert J, Aloise P. Age differences in the capacity
demands of a strategy among spontaneously strategic children. J Exp
Child Psychol. 1991;52:149 –165.
29. Kahneman D. Attention and Effort. Englewood Cliffs, NJ: Prentice-
Hall; 1973.
30. Navon D, Gopher D. On the economy of the human processing sys-
tem. Psychol Rev. 1979;86:214 –255.
31. Bardy B, Laurent M. Visual cues and attention demand in locomotor
positioning. Percept Mot Skills. 1991;72:915–926.
32. Geurts ACH, Mulder T, Nienhuis B, et al. Dual task assessment of
reorganization of postural control in persons with lower limb ampu-
tation. Arch Phys Med Rehabil. 1991;72:1059 –1064.
33. Shumway-Cook A, Woollacott MH. Attentional demands and pos-
tural control: the effect of sensory context. J Gerontol. 2000;55A:
M10 –16.
34. Shumway-Cook A, Woollacott MH, Kerns KA, et al. The effects of two
types of cognitive tasks on postural stability in older adults with and
without a history of falls. J Gerontol. 1997;52A:M232–240.
35. Brooks LR. The suppression of visualization by reading. Q J Exp Psy-
chol. 1967;19:289 –299.
36. Baddeley AD. Working Memory. Oxford, U.K.: Oxford University
Press; 1986.
140 Huang and Stemmons Mercer
37. Kerr B, Condon SM, McDonald LA. Cognitive spatial processing and
the regulation of posture. J Exp Psychol. 1985;11:617– 622.
38. Stroop JR. Studies of interference in serial verbal reactions. J Exp
Psychol. 1935;18:643– 661.
39. Jensen AR, Rohwer WD Jr. The Stroop color-word test: a review. Acta
Psychol. 1966;25:36 –93.
40. Manis FR, Keating DP, Morrison FJ. Developmental differences in the
allocation of processing capacity. J Exp Child Psychol. 1980;29:156 –
169.
41. White N, Kinsbourne M. Does speech output control lateralize over
time? Evidence from verbal-manual time sharing tasks. Brain Lang.
1980;10:215–223.
42. Kee DW, Davies L. Mental effort and elaboration: a developmental
analysis. Contemp Educ Psychol. 1988;13:221–228.
43. Hiscock M. Verbal-manual time sharing in children as a function of
task priority. Brain Cogn. 1982;1:119 –131.
44. Hiscock M, Kinsbourne M. Ontogeny of cerebral dominance: evi-
dence from time-sharing asymmetry in children. Dev Psychol. 1978;
14:321–329.
45. Hiscock M, Kinsbourne M, Samuels M, et al. Effects of speaking upon
the rate and variability of concurrent finger tapping in children. J Exp
Child Psychol. 1985;40:486 –500.
46. Hiscock M, Kinsbourne M, Samuels M, et al. Dual task performance
in children: generalized and lateralized effects of memory encoding
upon the rate and variability of concurrent finger tapping. Brain
Cogn. 1987;6:24 – 40.
47. Kinsbourne M, Hicks RE. Functional cerebral space: A model for
overflow, transfer, and interference effects in human performance.
In: Requin J, ed. Attention and Performance VII. Hillsdale, NJ: Erl-
baum; 1978:345–362.
48. Hiscock M, Kinsbourne M. Asymmetry of verbal-manual time shar-
ing in children: a follow-up study. Neuropsychologia. 1980;18:151–
162.
49. Murphy K, Peters M. Right-handers and left-handers show differ-
ences and important similarities in task integration when performing
manual and vocal tasks concurrently. Neuropsychologia.
1994;32:663– 674.
50. Caroselli JS, Hiscock M, Roebuck T. Asymmetric interference be-
tween concurrent tasks: an evaluation of competing explanatory
models. Neuropsychologia. 1997;35:457– 469.
51. Wickens CD, Benel DCR. The development of time-sharing skills. In:
Kelso JAS, Clark JE, eds. The Development of Movement Control and
Coordination. New York: John Wiley & Sons; 1982;253–272.
Pediatric Physical Therapy