Develop. Med.
Child Neural, 1972, 14, 747-755
Laterality and Dominance
Terminology
Laterality is the name for the pheno-
menon by which, in an organism with
paired faculties (hands, feet, eyes, ears),
the performance of certain tasks, afferent
or efferent, succeeds better on one side
than on the other. Laterality describes an
asymmetrical function. Subjectively, one
speaks of hand preference or foot prefer-
ence, meaning laterality. If preference is
not strongly unilateral, i.e. if the perform-
ance on both sides is more or less
qualitatively comparable, one speaks of
‘mixed laterality’ or inconsistence. ‘Crossed
laterality’ means that the preference is not
ipsilateral for the different faculties.
As the central pathways for input and
output cross the midline, the contralateral
cerebral hemisphere may play the major
part for the specific performance which is
lateralized. This seems to be true for
handedness and footedness, i.e. for the
output part of lateralized functions. For
the input, i.e. eyes, ears (and perhaps also
for other sensory functions), this organiza-
tion appears to be more complicated. In
the case of the eyes, for example, it is
important to distinguish between visual
field and retina, as the latter projects to
both hemispheres (though most people
claim to have a preferred eye for peeping
through holes, or aiming a gun). The
sensory input should also be differentiated
qualitatively in regard to central integra-
Department of Developmental Neurology, State University, Groningen, The Netherlands.
747
Bert C. L. Touwen
tion: for instance right-handed people
appear to hear and recognize digits faster
with the right ear, but to hear non-verbal
material faster with the left ear (Kimura
1964, Curry and Rutherford 1967). Simi-
larly, the identification of letters is more
rapid in t h e right visual field, but different
shapes are recognized more rapidly in the
left visual field (Bryden 1965, Rizolatti et a / .
1971). Such clear-cut differences are not
found in left-handed persons (Bryden
1965).
‘Dominance’ is the phenomenon in
which one cerebral hemisphere plays the
major r6le with regard to a specific
function. Dominance is a ‘central’ pheno-
menon. Dominance as such is non-
existent; it should always be specified. As
a result of the crossing of nerve fibers in
the central nervous system, the left
cerebral hemisphere is the dominant
hemisphere for handedness in right -
handers, and the right hemisphere for
left-handers. Again, this simple distinction
does not hold for sensory mechanisms.
The Relationship between Dominance and
Laterality
As it was found in clinical experience
that speech is usually localized in the brain
unilaterally, speech localization came to be
used for the identification of cerebral
dominance. Since Wada (1949) introduced
the intracarotid injection of sodium amytal

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
in order to identify the localization of
speech in the brain, this method has been
accepted as a reliable and relatively
innocent method for the demonstration of
the verbally dominant hemisphere (Branch
er al. 1964*).
More recently, unilateral electrocon-
vulsive therapy (ECT)has been reported as
a simpler and harmless method of examin-
ation (Pratt et al. 19717 ) .
In approximately 95 per cent of right-
handed individuals, the left hemisphere is
dominant for speech (Roberts 1969). I n
brain-bisected adults, Gazzaniga and Hill-
yard (1971) could demonstrate that the
minor hemisphere in right-handed people
plays a very inferior rale with regard to
speech and language capacity. However,
in left-handed individuals this is more
complicated. In only about 30 per cent of
left-handers does the right cerebral hemi-
sphere appear to be dominant for speech.
Generally speaking, in more than one-half
of the left-handed population the left
hemisphere is dominant for speech; in the
other half, speech and language functions
should be bilaterally localised (Roberts
1969). In patient material with well-
documented and comparable unilateral
damage, Htcaen and Sauguet (1971)
demonstrated that further differentiation is
necessary among the left-handed group.
While non-familial left-handers seem to be
very similar to right-handers in having
unilateralized speech and language, in
familial left-handers (i.e. left-handedness
in parents, siblings or immediate des-
cendants) a relatively bilateral representa-
* The sodium amytal is injected rapidly, while
the patient, lying on his back, counts and keeps
his arms raised and his knees drawn up and flexed.
During the contralateral hemiparesis, vigorous
testing of speech is carried out in the form of
naming objects, counting, and naming the days of
the week forwards and backwards.
t Tests consisting of naming three clear outline
drawings of common objects, and naming three
objects from verbal description are given at 7 and
20 minutes after the unilateral shock to determine
the presence or absence of dysphasia.
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1972, 14
tion seems to be the rule, with a less
marked intrahemispheric localization of
the neurological mechanisms underlying
the different language functions. Levy
suggested this in 1969, and argued that in
the case of left-handed people this would
be at the expense of the spatial functions
normally subserved by the right hemi-
sphere. Indeed, using the WAIS (Wechsler
Adult Intelligence Scale) to test post-
graduate students, she found right-handers
to be significantly superior with regard to
their performance IQ, while left-handers
and right-handers did not differ in verbal
IQ. Miller (1971) confirmed Levy’s findings,
using the NIIP*test forms on right-handed
and mixed-handed undergraduates. How-
ever, it is possible that the lower perform-
ance of the left-handers resulted from the
fact that most testing material is developed
for right-handers. I t is not clear
why spatial functions could not also be
represented bilaterally in the case of
bilateral verbal representation, and if so,
why they should suffer while verbal
performance does not. For sensory func-
tions such as vision and hearing, a
qualitative difference between left- and
right-handers could also be demonstrated.
It is generally believed that right-handed-
ness and right eye preference are related.
This relationship may of course be
weakened if refraction anomalies or other
disturbances of the receptor organ are
present. Zurif and Bryden (1969), using
dichotic listening and tachistoscopic recog-
nition tasks, found a consistent strong
right-sided superiority of both eye and ear
in the case of right-handers and non-
familial left-handers, while the familial
left-handers did not show a consistent
laterality for either eye or ear. Gronwall
and Sampson (1971), however, doubt the
* NIIP GroupTest 33 :test of verbal intelligence.
NIIP Form Relations Test: a test for visual
manipulation of shapes in both two and three
dimensions.

B. C . L. TOUWEN
existence of any correlation between
preferred eye and preferred hand. They
stress that ocular dominance does not
represent a single property, and that
Lederer’s classification of five types of
ocular dominance and Walls’ classification
of two types are not valid (Table I).
TABLE I
Types of ocular dominance
Lederer (1962)*
1. Monocular sighting and aiming.
2. Motor dominance of one eye in binocular
vision.
3. Orientational dominance, or position of the
binoculus.
4. Sensory dominance.
5. Dominance of one side of the visual field.
Walls (1951)*
1 . Sensory-perceptualdominance.
2. Motor dominance.
* Cited by Gronwall and Sampson (1971).
In their opinion we can only speak of
eye ‘preference’, which is highly dependent
on the number of tests, the quality of the
tests and the tempo at which they are
administered. Moreover, the examiner
should convince himself that the subject
understands correctly what is expected of
him, as well as the content of the test
items, so that the influence of the subject’s
intelligence on the test result can be ruled
out. On the other hand, McKinney (1967)
argued that the combination of left-
hemispheric dominance and temporal-
retina superiority could be an explanation
for the finding that, in binocular viewing,
the difference between the right and left
visual field is only significant for the left
eye in people with right-eye preference. In
the left eye, these factors would account
for a difference between the two halves of
the visual field, which is not the case for
the right eye (Fig. 1). This would account
-in the absence of peripheral sense-organ
disturbances-for the fact that most
individuals profess preference for one (i.e.
the right) eye. The argument of Eason
et al. (1967) that the amplitude of evoked
D 749
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left hemisphere right hemisphere
..
[I1 retlna projecting on dominant hemisphere
superior temporal retina
inferior nasal retina
Fig. 1. In an individual with dominance of the
left hemisphere there will be a considerable
discrepancy between both halves of the retina in
the left eye, but little or no discrepancy in the right
eye (McKinney 1967).
cortical potentials in the occipital lobes
was only related to handedness in the case
of left-handers remains unanswered. In
their study, the differentiation between
left- and right-handedness was very crude,
however, as it was based solely on the
subjects’ own impressions. Subirana (1969)
found no close relationship between
eye preference and hand preference among
children between 6 and 14 years of age,
although there seemed to be some increase
in the relationship with increasing age.
For hearing, Bakker (1970) demonstrated
with monaural stimulation in normal and
learning-disturbed children that although
the nature and degree of ear asymmetry
depended on the quantity of the presented
verbal material, the non-right-handed
subjects showed a lesser degree of ear
asymmetry than the right-handed subjects.
As was the case with dichotic stimulation,
right-handed and right-eyed children show-
ed a significant right ear preference for
verbal material. This tendency increased
with age. Lateral awareness played an
important r81e also: children with dis-
turbed awareness appeared to have a left
ear preference for verbal material, while
in obviously non-right-handed and non-
right-eyed individuals no preference could

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
be established. Finally, the findings of
Schwartz (1967) must be mentioned,
concerning the relation between brain
dominance and consciousness. Schwartz
claims a close correlation between hemi-
spheric dominance on the one hand and the
time of onset, the intensity and the
duration of disturbances of consciousness
on the other after unilateral intrahemis-
pheric white softenings, consciousness
being more severely impaired when the
dominant hemisphere is involved. How-
ever, his identification of dominance is
based on anamnestic information concern-
ing handedness only, which makes his
findings questionable.
It therefore seems that the relationship
between laterality and dominance is, in our
present state of knowledge, too complex
and at the same time too obscure to be of
much clinical value for the diagnosis of
intra-cerebral pathology.
Assessment of Handedness
Since most studies consider handedness
to be a parameter to which other functions
can be compared, it is essential to scrutin-
ize its assessment. Different methods have
been designed (Subirana 1969, Oldfield
1971, Steingruber 1971), but on the whole
one gets the impression that the confusion
increases with the number of test items.
Evidently, next to learning, the degree of
familiarity with the test items plays an
important r6le. Furthermore, as Oldfield
and Steingruber point out, the inter-
correlation of the items of a test battery
should be assessed, as they were able to
demonstrate that this intercorrelation could
vary considerably. This often makes a
comparison between different test batteries
difficult. In general, it may be taken for
granted that one-quarter of the population
is purely right-handed, one-third shows
right predominance, one-quarter has a
mixed preference, and one-sixth shows
left predominance. Pure left-handers prob-
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1972, 14
ably amount to I per cent or less of the
population. This pure left-handedness
should nearly always have a pathological
aetiology (Subirana 1969). Suchenwirth
(1969) suggests that the majority of people
are originally ambidextrous or of mixed
laterality for handedness, only 5 per cent
being primarily and what he calls 'biologic-
ally determined' right- or left-handed.
Social and cultural pressures are probably
responsible for the gradual increase in the
percentage of right-handers with age.
Data about footedness are rare. Gener-
ally, it is believed that footedness is closely
related to handedness, except in individuals
who were originally left-handed but were
successfully trained to right-handedness
(Benson and Geschwind 1968). This belief
may be regarded as a belief only. Forrai
and BBnkovi (1969) reported that no
relationship could be demonstrated be-
tween patterns of hand clasping or arm
folding and handedness. This was so in
Hungarian children, but there is no reason
to assume that this will be different in
other countries. The complexity of the
relationship between handedness and eye
or ear preference has been outlined
sufficiently.
The development of unilateral handed-
ness has long been under discussion.
Subirana (1969) discussed the widely
differing opinions of several authors and
concluded that, while most authors agree
that there is considerable instability of
manual preferences before school age in
most children, hand preference may
appear as early as the first year of life.
Passian et al. (1969) found that the
frequency of strong predominating left-
handedness and right-handedness increased
with age.
Sinclair (1971), using data from a
follow-up study of a small group of
children over 3 years of age, reported that
hand and foot preference usually seemed
stable after the age of 5 years, as was eye

B. C . L. TOUWEN
preference, Ear preference showed vari-
ation up t o the age of 7. She could not
demonstrate any relationship with reading
readiness scores.
Suchenwirth (1969) uses the term ‘oscil-
lation of hand preference’ between the
ages of 5 and 7 years to explain the often
ambiguous findings at these ages. He
concludes from his material that the
chance of finding right-handedness in-
creases with age.
Morphology
Evidence that one hemisphere should be
more equipped morphologically than the
other, and thus be the dominant one, is
controversial. Subirana (1969) cites several
studies which suggest that the left cerebral
hemisphere should contain more nerve
tissue than the right, but he concludes that
the morphological differences, if present,
are slight and that if there is a relationship
with handedness one has to take into
account that these studies are mainly
carried out on neurological patients, so
that the differences merely demonstrate
that pathological left-handedness may be
caused by lesions in the left hemisphere.
On the other hand, McRae et al. (1968)
claim that among right-handed individuals
the dominant hemisphere for speech
should be slightly smaller than the non-
dominant hemisphere, as they found that
the occipital horns of the lateral vertricles
were larger on the dominant side. They
also collected their data on neurological
patients, using air insufflation for diag-
nostic purposes. While the pattern of the
decussation of the pyramids in the medulla
oblongata shows a preponderance of first
crossing from the left to the right, a
relationship with handedness could not be
demonstrated (Kertesz and Geschwind
1971). Although the data about handed-
ness of these authors were collected
retrospectively from enquiries among rela-
tives, their results may be considered as a
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preliminary answer to the question about
the development of handedness put by
Yakovlev and Rakic, who found the same
preponderance in immature brains (Yakov-
lev and Rakic 1966, cited by Kertesz and
Geschwind 19711.
Aetiology and Clincial Meaning
Several factors have to be taken into
consideration regarding the aetiology of
laterality and dominance. In the first place,
a genetic factor will play a r6le. Oldfield
(1971) could demonstrate that the well-
known preponderance of left-handed males
over females is present in the total range
from slight left predominance to pure
left-handedness. He suggests that perhaps
the sex chromosomes may be involved.
Why right-handedness has been favoured
during evolution is not clear. It does not
seem to have a political background. It
stands to reason that among identical
twins a conspicuously largcr amount of
left-handers will be found than in the
general population, but the mode of the
heredity is still under discussion. Annett
(1964, cited by Subirana 1969) pointed out
that some left-handers ‘shift’ handedness
easier than others do; in her opinion these
left-handers could be called heterozygotic.
The situation is different for right-handers,
as there is more reason for left-handers to
become right-handers than vice versa.
Cultural pressure will stress the higher
value of right-handedness, so that peri-
pheral or central lesions will have a
differential effect on laterality. As a result
of brain damage, a shift towards the
undamaged hemisphere may or may not
occur, depending on the severity of the
lesion and the genetic anchorage. Still, as
the majority of the population is right-
handed, it is reasonable to suppose that
among left-handers relatively more ‘patho-
logical’ left-handedness may occur than
‘pathological’ right-handedness among
right-handers (Benson and Geschwind

DEVELOPMENTAL MEDIClNE AND CHILD
1968). The pathological left-hander is thus
the left-hander who became left-handed
because there was no other possibility for
him, despite social and cultural pressure
which always act in the direction of right-
handedness. The fact that so many
facilities of modern life are made for
right-handers increases the difficulties in
manipulative behaviour as well for ‘normal’
as for ‘pathological’ left-handers, which
would account for the increase of the
occurrence of slight clumsiness among
left-handed individuals.
Inverting the argument, it is often
stated that left-handedness and even
inconsistent handedness or crossed lateral-
ity may be a sign of neurological dys-
function, and stuttering, behavioural diffi-
culties, speech and language disorders and
mental backwardness are often said to be
related to left-handedness, mixed laterality
or crossed laterality. I do not believe that
such an inversion of the argument is per-
missible. Although, in clinical experience,
poorly established or inconsistent laterality
does seem to occur more frequently in
children with signs of neurological dys-
function (Paine and Opp6 1966), left-
handedness or mixed laterality occurs
with similar frequency among pupils in
special schools and in ordinary primary
schools (Author’s observations, unpub-
lished data).
As far as we know, the fact that an
individual is left-handed or has mixed or
crossed laterality has, of itself, no clinical
significance whatsoever. Hubbard (1971)
could not establish a relationship between
handedness and birth order (first and fourth
or later birth: high risk; second or third
birth: low risk) and also questioned the
relationship between the type of handed-
ness of children and their parents.
In considering the relationship between
left-handedness or mixed or crossed
laterality and behaviour, the findings of
Rutter et al. (1970) are relevant. Although
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NEUROLOGY. 1972, 14
(in agreement with the general clinical
experience) a significant preponderance of
left-handedness and left-footedness was
found among the children with neurologi-
cal disorders, a simple computation which
took into account the frequency of left-
handedness in the general population
showed that these types of lateralities are
of no use for diagnostic prediction.
Moreover, no association could be estab-
lished between inconsistent handedness or
footedness, crossed laterality for hands and
feet or hands and eyes on the one hand, and
signs of neurological disorders, specific
reading retardation or intellectual retard-
ation on the other hand.
Conclusions
1. The relationship between dominance
and laterality is very complex and still
largely unknown, especially in the case of
left laterality. Research in this field is of
major importance, as it may increase our
insight into brain mechanisms; however,
the implications for the clinician should
not be overestimated.
2. Dominance and, perhaps to a lesser
degree, laterality are not entities, neither
regarding brain localization nor considered
as brain functions. Dominance need not
be localized in the same cerebral hemi-
sphere for speech and language, manual
performances, o r visual or acoustic
functions.
3. The results of the testing for different
lateralities depends largely on the quality
and quantity of the tests administered.
Normative data are to some extent only
available for left and right-handedness.
For other functions associated with foot,
eye and ear dominance they are disap-
pointingly scarce. Elucidation of the
complexity of visual and acoustic laterality
is still in its infancy. Moreover, many
studies are carried out on patients with
neurological symptoms, whose perform-
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B. C . L. TOUWEN

ances cannot easily be extrapolated to SUBIRANA (1969):

normal individuals. Questions and observation concerning preferred
hand for
4. The evidence for a structural basis of eating dealing cards
hemisphere dominance is controversial. writing shuffling cards
The fact that most studies are carried out combing hair taking matches from box
on patient material may be largely respons- specific manual work corominas test
ible for this conflict. preference extensibility
throwing stones or ball threading needle
5. Standardized and well-conducted opening envelope clapping
studies on the development of laterality are hand puppets
also disappointingly scarce. Normative
THEEDINBURGH
INVENTORY
(OLDFIELD
1971)
data about the development of laterality
Questions concerning preferred hand for
during infancy and childhood are necessary writing broom (upper hand)
before any conclusions can be drawn about drawing striking match (match)
the significance of the type of laterality to throwing opening box (lid)
the neurological status of a child. scissors which foot do you prefer
tooth brush to kick with?
6. The often-claimed clinical relation- knife (without fork) which eye do you use
ship between neurological or behavioural spoon when using only one?
disorders and mixed or crossed laterality Score ++ or + in column for left and right;
is, at least, highly controversial. Further- if indifferent, score +in both columns. Add all
more, the relationship between left- +'s for each hand, subtract the sum for the left
from that for the right, divide by the sum of both
handedness and left-footedness and neuro- and multiply by 100. The result is the Laterality
logical disorders may not be interpreted as Quotient.
a causal one, without further evidence.
SUCHENWIRTH (1 969)

NOTE
After completion of this manuscript, the
author received a paper by Perlo and Rak
(1971). They examined a group of 50
dyslexic adults, and found 26 per cent to
be left-handed (without giving criteria),
and 34 per cent to have a similar family
history of developmental language dis-
orders. Their suggestion that therefore
heredity and left-handedness are connected
with the language disability seems far
from convincing on these grounds only,
and certainly needs further study and
confirmation.
A second paper, by Blakemore et al.
(1972), also discusses the asymmetry of
cerebral hemisphere function in man and
reaches the same conclusions as are given
in this paper.
Appendix
Tests used by different authors for the assess-
ment of handedness.
753
Observation of the preferred hand in 19 different
tasks such as throwing a ball; using scissors,
hammer, comb; opening cupboard; pointing to an
object; threading beads; crumpling up a piece of
paper; fending off; drawing or painting. Using the
left hand only gives a score of 0, using both hands
a score of 1 and using the right hand only a score
of 2.
STEINGRUBER (1971)
Evaluation of the performance of the left and
the right hand in tracing, tapping on a sequence
of squares, making patterns of dots, sorting out
beads and drawing a cross.
Calculation:
performance of right hand-performance
of left hand
sum of the performance of right and left hand
Score: --I = pure left-handedness; 0 = ambi-
+
dexterity; 1 = pure right-handedness.
It is evident that not only do the test batteries
themselves differ substantially, but also the way in
which the results are calculated. This makes it
difficult to compare the findings.
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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1972, 14

SUMMARY
Laterality, hand preference and cerebral dominance are terms which are often used
synonymously. They should be differentiated, however. A review of the literature demon-
strates much (often eclectic) knowledge which is often not directly applicable clinically.
Moreover, comparison of the results of different authors is hampered by the fact that they
use different test batteries.
One of the conclusions reached in this paper is that a finding of left-handedness or
crossed laterality should not be regarded as a neurological sign without further evidence.

R I ~ U M ~
LatCralitk et dominance
La lattraliti, la preference manuelle et la dominance cerebrale sont des termes qui sont
souvent utilisks l’un pour I’autre et qui devraient pourtant Ctre diffirencies. Une revue de la
littkrature sur la dominance fournit de trtts nombreuses informations souvent iclectiques
et qui n’ont pas d’application clinique directe. De mCme la comparaison des resultats
fournis par differents auteurs est alterbe par le fait qu’ils utilisent diffkrentes batteries de
tests. La conclusion principale tirCe de I’etude prisente est que la dkcouverte d’une gau-
cherie ou d’une lateralit6 croisCe ne doivent pas Ctre regardtes en soi comme des signes
neurologiques anormaux.

ZUSAMMENFASSUNG
Seitenbetonung und Dominanz
Seitenbetonung, Handigkeit und Hemispherendominanz sind Begriffe, die haufig synonym
gebraucht werden, die jedoch voneinander unterschieden werden sollten. Das Literatur-
studium iiber die Dominanz gibt viele, z.T. ausgewahlte Informationen, die keine direkte
klinische Anwendung haben. Und wieder ist ein Vergleich der Ergebnisse verschiedener
Autoren nicht moglich, da sie sich verschiedener Testanordnungen bedienten. Der wichtigste
Befund der vorliegenden Studie ist, darj das Auftreten von Linkshandigkeit oder gekreuzter
Seitenbetonung als einzelnes Symptom nicht als abnormes neurologisches Zeichen gewertet
werden sollte.

RESUMEN
Lateralidad y dominancia
Lateralidad, preferencia manual y dominancia cerebral son terminos que se usan a
menudo de forma sinhima pero que deben ser diferenciados. Una revision de la literatura
sobre la dominancia muestra mucha y a menudo ecltctica, information que no tiene una
aplicacion clinica directa. AdemBs, una comparacion de 10s resultados comunicados por
diferentes autores esta dificultada por haber usado baterias de tests diferentes. Una con-
clusion mayor obtenida del presente estudioes que el hallazgo de una zurderia o de una
lateralidad cruzada, no deben ser considerada por si solo como un signo de anomalia
neurologica.
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8. C. L. TOUWEN

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