Soft Neurological Signs in Learning\x=req-\
Disabled Children and Controls
Richard M. Adams, MD; Jenci J. Kocsis; Robert E. Estes, PhD
Learning-disabled fourth graders were
compared with a control group for incidence
of selected neurological signs. Factors eval-
uated were eye-hand preference, balance,
stereognosis, graphesthesia, hand-finger im-
mobility (abnormality, choreoathetosis), fin-
ger localization, and diadochokinesia. Color
vision and head circumference were also
evaluated as possible correlates of learning
disability. Although two of the functions
tested (graphesthesia and diadochokinesia)
were significantly depressed in the learning\x=req-\
disabled group compared with results in the
control group, the magnitude of difference
was not great enough for clinical usefulness.
some time, controversy has
For existed in the literature over the
relevance of soft neurological signs in
children with learning disorders.
Hundreds of publications later, we
are scarcely nearer a resolution of the
controversy, primarily due to poorly
controlled studies and insufficient
Received for publication March 7, 1974; ac-
cepted May 5.
From the Department of Pediatrics, Univer-
sity of Texas Southwestern Medical School (Drs.
Adams and Estes and Mr. Kocsis); and the Re-
search and Evaluation Center for Learning (Drs.
Adams and Estes), Dallas.
Reprint requests to 3700 Ross Ave, Dallas, TX
75204 (Dr. Adams).
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normative data.
The goal of this study was to com¬
pare groups of learning-disabled, bor¬
derline-disabled, and control fourth
grade children, with respect to inci¬
dence of variations in selected soft
neurological signs. This term is
broadly defined as those neurological
variations that are equivocal or inter¬
mittent, and consequently may be
overlooked during neurologic exami¬
nation. A review of the literature
relative to the measurements eval¬
uated disclosed limited and often in¬
conclusive data. In the motor realm,
Denhoff and Siqueland1·2 have sug¬
gested that a positive relationship ex¬
ists between a child's ability to per¬
form diadochokinetic tasks and his
school performance. Grant et al3 have
claimed that increased proficiency of
diadochokinesia is a function of age
with full development at 9 to 10
years. Rutter and Birch4 and Prechtl5
have noted the association of chorei¬
form movements with hyperkinesis
and learning problems, while other
authors2·6·8 have found positive corre¬
lations between clumsiness and poor
school performance.
In the sensory realm, probably the
best norms for graphesthesia and
stereognosis are to be found in the
Southern California Kinesthesia and
Tactile Perception Tests of Ayres.9
The same author10 has recently re¬
ported constellations of sensory in¬
tegrative dysfunctions (including
poor graphesthesia) in 6%- to 8%-
year-olds with academic disorders.
Spreen11 has reported norms for
stereognosis, however, no studies
were found in the literature relating
astereognosis to poor reading or glo¬
bal school performance. The associa¬
tion of finger agnosia and dyscalculia
is well known,1213 though apparently
rare. Benton,14 in a study of 158 nor¬
mal children aged 5% to 9% years, re¬
ported that finger localization skills
do not attain maturity until late
childhood. He cautions that norma¬
tive data per se do not necessarily in¬
dicate that low scores possess patho¬
logical implications, but suggests
poor performance may be predictive
of cerebral dysfunction.
Miscellaneous indexes reviewed in¬
cluded color vision, eye-hand prefer¬
ence, and head size. At least one au¬
thor15 has suggested a correlation
between hereditary color-vision defi¬
ciency and learning disabilities. The
majority of well-controlled studies16-20
indicates no relationship between
mixed eye-hand preference and read¬
ing ability; however, this factor con¬
tinues to be cited as a correlate of
 poor school performance in several
school districts. In relation to head
circumference, there is a known cor¬
relation between microcephaly and,
to a lesser degree, macrocephaly with
low intelligence. It has been postu¬
lated that there might be a portion of
learning-disabled children with un-
diagnosed, arrested hydrocephaly.
From these investigations, it can
be seen that interstudy comparisons
are difficult, due to lack of uniformity
of testing procedures and the hetero¬
geneity of subjects. This study was
designed in an effort to eliminate
some of these shortcomings.
Clinical Population
and Methods
The specific neurologic measurements
evaluated in this study include the follow¬
ing: (1) eye-hand preference; (2) balance;
(3) stereognosis; (4) graphesthesia; (5)
hand-finger immobility (abnormality, eho-
reoathetosis); (6) finger localization; and (7)
diadochokinesia. Although not considered
"soft signs," color vision and head circum¬
ference were evaluated as possible corre¬
lates of learning disability. These indexes
were chosen on the basis of frequency of
occurrence in the literature, ease of admin¬
istration, and, in some instances, because
of quantifiable characteristics.
The sample consisted of 368 fourth grad¬
ers in 18 research classrooms from the
Dallas and Irving Independent School Dis¬
tricts. The age range was 9 years, 3
months to 11 years, 8 months with a mean
of 10 years, 2 months and a standard de¬
viation of 5 months.
All children had been administered the
Metropolitan Achievement Test (MAT)
and a group intelligence test (the Califor¬
nia Test of Mental Maturity for the Dallas
children and the Short Form Test of Aca¬
demic Aptitudes for the Irving children).
Myklebust Learning Quotients21 were com¬
puted for all children using the total read¬
ing, spelling, and math computation grade-
placement scores from the MAT. The low¬
est of these three quotients was utilized
for classification. A child whose learning
quotient was 90 or above was classified as
normal (N), 85 to 89 as borderline (B), and
84 or below as learning-disabled (LD),
yielding 130, 99, and 139 children in each
group, respectively. The normal group
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(hereafter referred to as the control group)
differed from the other two groups only in
its learning quotient. In addition to the
learning quotient, each child met the fol¬
lowing criteria: an IQ of 85 or above on the
group intelligence test; and an absence of
significant visual or auditory acuity defi¬
cits, as determined by a school screening
examination resulting in a visual acuity of
at least 20/30 OU on the Snellen chart at 20
ft and passing a five-frequency audiogram
at 25dB; no physical handicaps or major
motor dysfunctions were noted on routine
school health examination by the child's
physician. In addition, no child was ac¬
cepted for the study whose school records
indicated referral for a possible emotional
problem.
The subjects entered a quiet, unoccupied
classroom in pairs with each child attend¬
ing separate stations for administration of
half the test items and exchanging sta¬
tions for completion of the items. Parti¬
tions were employed between stations to
reduce visual distraction. Examiners were
unaware of any child's learning classifica¬
tion during the testing period. Individual
items were administered as follows:
Motor Items.—Diadochokinesia.—Subject
was asked to tap a hand-controlled tally
counter alternately with the palm and dor-
sum of his dominant hand as fast as pos¬
sible for ten seconds. Following a demon¬
stration and practice session, two trials
were run and the number of taps regis¬
tered by the counter was recorded for the
second trial. The same procedure was fol¬
lowed for the nondominant hand.
Hand-Finger Immobility (abnormality,
choreoathetosis or choreiform movements).—
The subject was asked to imitate
the examiner in extending the hands (6 in
above table while seated) and spreading
the fingers. He was directed "see if you
can keep your hands and fingers as still as
I can for one minute." Praise was given at
30 seconds, regardless of performance. A
subjective assessment was made by the ex¬
aminer (R.M.A.) as to whether choreo-
athetotic movements of the hands, fin¬
gers, or arms were constant, occasional,
absent.
Balance. -Standing (on one foot for 30
seconds): The subject was asked to imitate
the examiner (R.M.A.) by lifting one foot
(subject's choice) and placing it against the
opposite knee while keeping both arms at
his side. The subject was assessed as "awk¬
ward" if during the 30-second test period,
his elevated foot touched the floor, he used
his arms, shifted his floor foot excessively,
or employed wide amplitude torso gyra¬
tions to maintain balance. Hopping (30
times on foot of subject's choice): Subject
was assessed as awkward, if hopping
was entirely flatfooted and slower than one
hop per second. On both the standing and
hopping tasks, the subject was permitted
three unsuccessful trials before being clas¬
sified as awkward. If the subject was clas¬
sified as awkward on either task, he was
considered to have poor balance.
Sensory Items.—Stereognosis.—Subject
was first asked to name by visual inspec¬
tion four coins (quarter, nickle, dime, and
penny), then to identify them "by feel"
with vision occluded. Twenty identification
trials were administered (five for each
coin) in a predetermined sequence with
each coin succeeding itself once; auditory
clues were avoided. No practice was given
and the number of errors for the 20 trials
was recorded.
Graphesthesia.—Subject was told that
numbers would be "drawn" on his hand for
him to identify. A ballpoint pen with the
stylus retracted was used to draw single
digit numbers (zero through nine) on the
palm of the dominant hand, positioned for
correct "visual" orientation; the eyes were
occluded. One orientation trial was admin¬
istered and any errors made were cor¬
rected. All digits appeared twice; no num¬
ber succeeded itself. Twenty trials were
administered in a predetermined sequence
and the number of errors recorded.
Finger Localization.—Subject was seated
at a table with his dominant hand inserted
palm down into a visual occlusion box14;
fingers were spread flat against the box
floor. The test consisted of the examiner
touching two of the subject's fingers simul¬
taneously on the dorsum of the proximal
phalynx at its midpoint. The examiner
used the pulp portion of his distal
phalynges to apply approximately one
gram of pressure for one second. The sub¬
ject was not allowed to move his fingers to
add kinesthetic clues. Ten combinations of
or the fivefingers (index-thumb, ring-middle,
etc) were administered twice each in a pre¬
determined order; no combination suc¬
ceeded itself. The subject was then asked
to indicateon a line drawing of a hand
(digits numbered one to five) the two fin¬
gers touched, either by pointing or giving
the numbers of the fingers. A practice trial
of three of the combinations was given
 and all errors corrected. The number of er¬
rors for the 20 trials was recorded.
Color Visicra.-Subject was asked to
identify all number items on the Ishihara
Color Plates (adult form, 1973). Presence
of normal or abnormal color vision, as de¬
fined in the test manual, was noted.
Miscellaneous Items.—Eye-Hand Prefer-
ewce.-Subject was asked to look through a
child's kaleidoscope handed to him in the
midline, at chest level. The same procedure
was then followed with a plastic tube
("telescope"). If he used the same eye for
both, this eye was recorded as the pre¬
ferred one; if not, two additional trials
with each instrument were given. If at
least four of six trials were unilateral, the
gated. Variation (dysfunction) was
defined by two methods. One was to
establish the criteria for dysfunction
prior to administering the tasks; with
each child either meeting or failing to
meet the criteria. This procedure was
utilized forhand-finger immobility,
balance, eye-hand preference, and
color vision, with the criteria for each
factor as described previously. The
second method was to define vari¬
ation statistically. This was accom¬
plished by determining the mean and
standard deviation for each parame¬
ter and defining poor function as a
score that was 1.5-SD units or more
sents the percent of children, by
learning classification and sex-exhib¬
iting variations from the norms, in
each of the neurologic functions in¬
vestigated.
To compare the differences be¬
tween the learning classification
groups with respect to incidence of
variation in the neurological func¬
tions, 2 tests with one degree of free¬
dom, using Yate's correction for con¬
tinuity,21 were applied with each
measurement and are reported below.
Motor Items.—Dysdiadochokinesia.
—A
significantly greater incidence
( 2 4.46, P<.001) was found in the
=

subject was considered to have an eye pref¬
erence. In addition, the hand used by the
subject in writing his name was recorded.
If the subject lacked eye preference, or if
the preferred eye and hand were not uni¬
lateral, he was considered to have mixed
eye-hand preference.
Head Circumference.-The frontooccipi-
tal circumference was measured with a
from that mean. For head circum¬
ference, published means and stan¬
dard deviations were used to deter¬
mine the variation.22 There are no
normative data for the procedures
used in testing diadochokinesia, ster-
eognosis, graphesthesia, and finger
localization. For these measurements,
LD boys than in the control boys
when comparing variations with the
dominant hand. No other reliable dif¬
ferences were obtained when compar¬
ing learning classifications. Within
both the and LD classifications,
boys had significantly greater inci¬
dence than girls ( 2 4.46, P<.05;
=

steel tape measure. The largest of three the means and standard deviations of
measurements was recorded to the nearest
2 13.95, P<.001, respectively). Com¬
=

the controls, as previously defined by parisons of variations with the non-

0.2 cm.
use of the Myklebust Learning Quo¬ dominant hand indicated a signifi¬
Results
tient, were calculated for each sex cantly greater incidence ( 2 7.79, =

separately and used as normative P<.01) in the LD girls than in the

In order to compare the LD, B, and
control groups with respect to inci¬
dence of neurological variations, the
concept of variation was first defined
for each of the measurements investi-
data to define variation. Table 1 pre¬
sents the normative data by learning
classification and sex as well as the
cut-off points defining variations for
the above parameters. Table 2 pre-
control girls. Other comparisons
among learning classifications did not
yield significant differences. Girls had
a significantly greater incidence than
boys ( 2 3.88, P<.05) in the LD
=

Table 1.—Normative Data and Cutoff Points for Neurological Measurements by Learning Classification and Sex

Cutoff Points,
Control Borderline Learning Disabled 1.5 SD from M
of controls
52 78 53 46 83 56
Neurological Measurements M F M F M F M F
Diadochokinetic rates,
taps/10 sec
Dominant hand M 30.35 29.49 29.23 29.09 28.27 28.62 26.34 23.80
SD 2.67 3.79 3.67 3.26 3.40 4.65
Nondominant hand M 26.73 27.10 26.70 26.59 25.06 25.09 21.99 21.47
SD 3.16 3.75 3.97 3.16 3.22 4.45
Stereognosis for coins,
No. of errors M 2.13 2.96 3.02 3.46 2.37 3.18 5.66 6.47
for 20 items SD 2.35 2.34 2.49 2.75 2.24 2.18
Graphesthesia for numerals,
No. of errors M 3.00 2.56 5.15 3.52 4.24 4.55 6.24 6.85
for 20 Items SD 2.16 2.86 3.55 3.36 3.19 3.61
Finger localization,
No. of errors M 3.48 4.21 4.91 4.65 3.89 4.50 7.47 8.62
for 20 items SD 2.66 2.94 3.40 3.54 2.58 2.85

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 Table 2.—Percent of Children by Learning Classification and cidence of either large or small head
Sex-Exhibiting Variations in Neurologic Functions circumference (+ and —1.5 SD from
M, respectively) were noted among
Control Borderline Learning Disabled learning classifications. In comparing
Neurological 52 78 53 46 83 56 incidence between boys and girls,
_Variation_M_F_M_F_M_F_
Motor items
small head circumference was sig¬
Dysdiadochoklnesia
nificantly more frequent in girls
Dominant hand 7.7 9.0 20.8 4.3 33.7 5.4 ( 2 6.35, P<.05; 2 13.36, P<.001;
= =

Nondomlnanthand 3.8 6.4 7.5 8.7 10.8 25.0 2 15.07, P<.001 for the control, B,
=

Choreoathetosis and LD groups, respectively). None of

Occasional 19.2
Constant 17.3
Poor balance_32.7
Sensory items
Poor stereognosis 9.6
Poor graphesthesia 9.6
Poor finger localization 7.7
Color deficient
Miscellaneous Items
vision_3J3_CL0_5^7_0_ _8^4_0.0
Mixed laterally 23.1
Head circumference
-1.5 SD from M 1.9
+1.5 SD from M 7.7
classification but no sex differences
were found in either the control or
groups.
Choreoathetosis.—No significant dif¬
ferences in incidence were found
among any of the learning classifica¬
tions for either occasional or constant
choreoathetotic movements. A signif¬
icant sex difference was obtained
( 2 5.20, P<.05) that indicated that
=
the boys had a greater incidence of
occasional choreoathetosis than the
girls. Boys also had a greater inci¬
dence than girls ( 2 =11.94, P<.001)
of constant choreoathetotic move¬
ment in the control group.
Poor Balance.-There were no sig¬
nificant differences in incidence
among learning classifications for ei¬
ther boys or girls. Within all three
classifications, however, the boys had
a significantly greater incidence than
the girls ( 2 7.45, P<.01; 2 =7.06,
=
P<.01; 2 11.01, P<.001 for the con¬
= dence among learning classifications.
trol, B, and LD classifications, respec¬
tively).
Sensory Items.—Poor Stereognosis.—
Differences among learning classifi¬
cations and between sexes disclosed
no reliable differences in incidence.
Poor Graphesthesia.—The LD girls
had a significantly greater incidence
10.3 28.3 10.9 30.1 17.9
0.0 15.1 2.2 6.0 0.0 the differences was reliable with re¬
11.5 35.8 10.9 44.6 16.1 spect to large head circumference.
Diadochokinesia, stereognosis,
9.0 13.2 15.2 12.0 10.7
11.5 35.8 19.6 22.9 26.8 graphesthesia, finger localization, and
9.0 22.6 13.0 9.6 7.1 head circumference were amenable to
evaluation by analysis of variance
46.2 28.3 52.2 36.1 42.9 techniques. Results of the analysis in¬
dicated that only two of the factors,
17.9 0.0 28.3 4.8 30.4 diadochokinesia and graphesthesia,
1.3 11.3 0.0 4.8 1.8
produced reliable differences among
learning classifications. The diadocho-
kinetic rate for the dominant hand
than control girls ( 2 4.17, P<.05),
=
was significantly faster (P<.005) in
while the incidence in the boys was the control as compared to the LD
significantly greater than that in the group, with no significant differences
control boys ( 2 8.81, <.01). The re¬
=
noted between the and either the
maining differences among learning control or LD groups. The rate for the
classifications and those between nondominant hand was significantly
sexes were not reliable. faster (P<.01) for both the control
Poor Finger Localization.-differ¬ and as compared to the LD groups,
ences in incidence were not reliable with no reliable differences indicated
either when comparing by learning between the rates of the control and
classifications or by sex. children. The number of errors
Poor Color Vision.—'No significant made in graphesthesia was signifi¬
differences in incidence were ob¬ cantly less (P<.001) for the control
tained among learning classifications group when compared to both the
or between sexes. When the incidence and LD groups, with no reliable dif¬
figures in the present study are com¬ ferences indicated between the rates
pared to those for color blindness in of the latter two groups.
the general population, the LD chil¬
dren are quite comparable to pub¬ Comment
lished norms.24 A significantly greater incidence of
Miscellaneous Items.—Mixed Eye- dysdiadochokinesia was found in the
Hand Preference.-There were no re¬ LD boys than in the control boys
liable differences with respect to inci¬ when comparing variations with the
dominant hand. Comparisons of vari¬
For both the control and classifica¬ ations with the nondominant hand
tions, girls had a significantly greater disclosed a significantly greater inci¬
incidence than boys ( 2 6.18, P<.05;
= dence in the LD girls than in the con¬
2 4.92, P<.05, respectively). This
=
trol girls. No significant differences in
difference was not noted with the LD incidence were found among any of
children. the learning classifications for poor
Variation in Head Circum¬ stereognosis, choreoathetotic move¬
ference—No reliable differences in in- ments, poor balance, mixed eye-hand

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 preference, color blindness, or poor
finger localization. Neither were sig¬
nificant differences found among
learning classifications for head size,
which deviated 1.5 SD or more from
the mean. Although two of the func¬
tions tested (diadochokinesia and
graphesthesia) were significantly dif¬
ferent in the LD group as compared
to the control group, the magnitude
of the differences was not great
enough to make it helpful in differ¬
entiating the two groups clinically.
The combination of both conditions
showed only 13.7% of the LD group
and included none of the control
children.
In looking for possible cases of de¬
velopmental Gerstmann syndrome,12
seven subjects (1.9%) were identified
with both poor finger localization
(finger agnosia) and math-learning
quotients below 85 (dyscalculia).
There were 34 (9.2%) additional sub¬
jects with finger agnosia only.
It is apparent that 9- and 10-year-
old learning-disabled children cannot
be reliably distinguished from nor¬
mally achieving children on the basis
of the soft neurological signs outlined
in this study. Thus, classroom obser¬
vation and selected psychoeducation-
al testing would appear the logical
approach to identification of learning
disabilities, at least for older elemen¬
tary children. For the present, gen¬
eral physical examination and vision
and hearing screening should consti¬
tute adequate initial medical eval¬
uation for the large majority of school
children with learning disorders. Ob¬
vious exceptions would be suspicion of
seizure disorder or hyperkinesis that
would merit special pediatrie or neu¬
rologic consultation. It must be cau¬
tioned that these results should not be
extrapolated to younger children, as
the incidence of soft neurological
signs is an age-related phenomenon.
However, as early identification and
educational intervention improve
prognosis, the authors plan to repli¬
cate this study with first and second
grade children. It is hoped that other
investigators will employ uniform
testing procedures to facilitate in-
terstudy comparisons not currently
possible.
This investigation was supported in part by a
grant from the Jonsson Foundation and the Edu¬
cation Service Center, Region X to the Research
and Evaluation Center for Learning through the
Department of Pediatrics, University of Texas
Southwestern Medical School at Dallas.
John Nelson, MD, and Michael Blaw, MD,
made helpful suggestions during preparation of
the manuscript.
Consent for use of subjects in this study was
obtained from the parents or guardians after the
nature of the procedures had been fully ex¬
plained.

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