Disorders and Motor
Coorhtion in Chldren
Sharon A. Cermak, Elizabeth A. Ward,
Lorraine M. Ward
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Key Words: dyspraxia apraxia .sensory
integration . . . . . . . . .
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. -2his study was designed to examine- the -relationship--
between articulation disorders,,soJt neurological
signs, and motor abilities. FiJteen children with ar-
. . ~
ticulation problems, as measu-red b)! the _Tetnplitr - -.-I
Darley Articulation Screening Test and a con-
nected speech sample, were compared with a nor-
mal control group (matched for sex and age) on the
Quick Neurological Screening Test, the Imitation of
Postures test (from the Southern CaliJornia Sensory
Integration Tests), and the 1984 version of the Stott
Test ofMotor Impairment that has been reuised by
Henderson. A sign $cant d~yererzce was foic?rd be-
tween the groups on the Motor Impairme?rt Test and
the Quick Neurological Screening Test, sitpportirzg
the hjpotl~esis that the articltlation disorder chil-
dren woitld haue more motor coordination prob-
lems and soft neurological signs than tl~e normal
children in the controlgroilp. TI~ere was no be-
tween-group drfferetice on the Imitation of Postures
... - - - - -. .. - test, -szcggesting that as a group; children with artic.---
ulatiorr deficits are not djsprauic. This stud)? sitp-
ports other research findings stating a relationsl~ip
between articitlation problems and rnotor irnpair-
ment, but it also indicates that this motor impair-
ment is not necessarily djlspraxia.
Sharon A. Cermak. EdD, OTR, FAOTA, is Associate Profes-
sor of Occupational Thempy, Boston University, Sargent
College, 1 University Road, Boston, Massachusetts 02215.
She is also a Faculty Member of Sensory Integntion Inter.
At the time of this study, Elimbeth A. Ward was an occupa-
tional thenpy graduate student in a master of science de-
gree program, Boston University, Sargent College.
Lorraine M. Ward, MA, is a speech-language pathologist,
Lexington Public Schools. Lexington, Massachusetts.
Cermak, Coster, & Drake, 1980; Conrad, Cermak, &
Drake, 1983). A high incidence of articulation prob-
lems has consistently been noted in these children
(Abbie, Douglas, & Ross, 1978; Ayres, 1972; Gubbay,
1975). Conversely, speech therapists working with
children who have articulation problems have noted
that these children have more motor problems than
do their peers (Bilto, 1941; Jenkins & Lohr, 1964).
:_iThis apparent relationship between deficits in articu-
lation and deficits in motor coordination has been
examined by a number of investigators (Bernthal &
Bankson, 1981) and some studies have indeed found
a relationship between severe articulation problems
(referred to as developmental apraxia of speech) and
problems in motor coordination (sometimes referred
to as motor dyspraxia) (Bilto, 1941; Jenkins 8r Lohr,
1964; Prins, 1962). Unfortunately, other studies have
- --indicated that there is no relationship (Aram & Hor.
witz, 1983; Reid, 1947). In addition, children with
motor dyspraxia as well as children with develop-
mental apraxia of speech have been shown to have a
higher incidence of soft neurological signs (Kornse,
Manni, & Rubenstein, 1981; Rosenbek & Wertz, 1972;
Yoss & Darley, 1974), even though one study did not
concur with this outcome (Williams, Ingham, & Ro-
senthal, 1981). Since children are typically identified
and treated earlier for speech deficits than they are
for motor coordination deficits (Gubbay, 1979; Wil-
liams, Ingham, 8r Rosenthal, 1981), the relationship
between these problems ought to be of major concern
to occupational therapists because more than 1.3 mil-
- -- lion children have functional articulation problems
(Yoss 8r Darley, 1974) and are unable to correctly
pronounce sounds although they do not display pa-
ralysis, weakness, or deformities (Reid, 1947). If a
relationship between articulation deficits and prob-
lems in motor coordination exists, many of the chil-
dren being seen for articulation problems should also
be screened for motor problems and considered for
occupational therapy services.
Various theories have been proposed to explain
functional articulation problems in children. At one
time articulation problems in children were thought
to be similar to the expressive aphasias seen in adults
with lesions to Broca's area (Rosenbek 8r Wertz,
1972). However, it has been shown that articulation
problems in children are not the result of specific
lesions of the left hemisphere (Kornse, Manni, &
Rubenstein, 1981; Rosenbek & Wertz, 1972). It ap-
pears that the praxis centers for speech movement
may be diffuse in the child's brain, whereas the con-
trol of speech is localized in the adult. Thus, the
any occupational therapists are involved in
remediating problems in motor coordina-
tion and dyspraxia in children (Ayres, 1972;
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understanding of adult brain lesions has not provided
answers to apraxia in children (Rosenbek & Wertz,
- Motor dyspraxia also has an unknown etiology.
Gubbay (1975, 1979) has hypothesized a multifacto-
rial etiology to explain motor dyspraxia, which may
include perinatal influences and alterations of cere-
bra1 organization. Ayres (1972, 1980a) believes that
motor dyspraxia is the result of a disorder of sensory
integration. Both motor dyspraxia and developmental
apraxia of speech seem to be sensitive to interfer-
enc.es..fr~m iaueunidentified .sources-(Jenkins=.&:=
This study is designed to further examine the_--
relationship between articulation deficits, soft neu-
rological signs, impairments in motor coordination,
and motor dyspraxia. It is hypothesized that children
. -.-with -articulation--problems
than children without articulation problems on the
Quick Neurological Zcreenig-TTst ( ~ u t t i , Sterling,-
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aiding;-1978);-and on tests of motor coordination
The subjects were 30 children from a middle- to'upper
middle-income suburban public school in Massachu-
setts. They ranged in age from 5 to 8 years. Fifteen
subjects had functional articulation problems, and 15
subjects (the control group) did not have functional
All subjects in the articulation disorder group
were jdentified by the speech and language patholo-
- - - gist in their school as having articulation problems.
In addition, they scored below the -1 standard devia-
tion score on the Templin-Darley Articulation Screen-
ing Test (Templin & Darley, 1964) and/or demon-
strated 10% or more misarticulated words in a speech
sample of 50 connected words. The mean standard
score on the Templin-Darley was -1.86 (SD = 1.98),
and the mean word error score on the connected
speech sample was 24.80% (SD = 19.25%). All chil-
dren in the articulation group had normal receptive
language skills (standard scores equal to or greater
than 85) as assessed by the revised Peabody picture
vocabulary test (Dunn & Dunn, 1981). The mean
score on the Peabody was 114 (SD = 12.7).
The control group was matched with the articu-
lation disorder group by sex and age (within G
months). The mean age (and standard deviation) for
the control and articulation disorder groups was 82.6
months (11.7 months), and 82.7 months (11.7
months), respectively. There were 9 boys and 6 girls
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- & Sp
and planning, specifically the Test of Motor Impair-
ment (Stott, Moyes, & Henderson, 1984), and the
'Imitation of Postures test (Ayres, 1980b).
in each group. All subjects were free from obvious
physical limitations such as deformities, paralysis, and
weakness. No child in either group was diagnosed as
being learning disabled.
Templin-Darley Articulation Test. The 50-item
screening subtest of the Templin-Darley Articulation
Test was used to assess the general accuracy of the
subjects' articulation. The stimuli are line drawings,
and subjecls are-asked to identify items in the draw-
- ing. The subjects' total number of correctly identified
items was compared with the mean number of items
.- produced by children of the same age in the standard-
, ization sample. A standard deviation score was calcu-
lated for each subject.
Connected Speech Sample. Conversational
-- speech was elicited to assess articulation with stan-
dard questions asked of the child about his or her
---address; dassroom, and family. The child also named
some numbers and colors. The conversational speech
was tape-recorded, with the first 50 words being eval-
uated for articulation disorders. The percentage of
incorrect words in the sample was calculated for each
Peabody Picture Vocabula y Test-Revised Form
hl. This test assesses receptive vocabulary using single
words. A raw score is converted to a language quotient
related to the age of the subject.
Quick Neurological Screelzing Test. This is a 15-
item screening test, which relates neurological inte-
gration to learning. The test aids in the identification
of children with learning disorders. Scores were to-
taled for each subject in accordance with the instruc-
tions in the test manual. In addition;scores were
categorized as normal, suspiciorrs, or impaired. A
score of 25 or less is considered normal, scores
between 25 and 50 are considered suspiciorts, and
scores above 50 indicate that a subject is inrpaireci.
Prior to categorization, scores were recalculated to
take the subjects' age into account.
Test of hlotor Impairnret~t-Revised 1984. This
test is based on the Oseretsky Tests of Motor Profi-
ciency (Doll, 1946). It is a screening test designed to
detect impairment of motor function. Eight items for
each age level are presented. These items include
ball skills (catching and throwing), unimanual and
bimanual dexterity, and static and dynamic balance.
Each item is scored with zero points for passing, one
point for borderline performance and two points for
a performance that has been determined to represent
failure. Thus the range of scores is 0-16. Scores are
categorized as inlpaired (4 + points) or tzotzinlpaired
(0-3.5 points) motor performance.
The America~z]ozrr~zal of Occzrpcltiorral Tl~erapj~
Imitatiotz o f Postures Test. This test is one of the
tests of the Southern California Sensory Integration
Tests (Ayres, 1980b). "It requires the child to assume
a series of positions and/or postures demonstrated by
the examiner, a process that requires motor planning
or programming a skilled or nonhabitual motor act"
(Ayres, 1980b, p. 5). The test is used to assess motor
dyspraxia. Scoring is based on completion or partial
completion of the posture, or the inability to assume
the posture, and the time it takes to assume the
posture. Raw scores are converted to standard scores
according to the age of the subject.
Procedures. Subjects were tested on the Templin-
Darley Articulation Screening Test and a sample of
connected speech. If the subject's standard deviation
scores were less than - 1.0 on - the Templin-Darley
and/or they made 10% or more errors on the words
in the connected speech sample, they were placed in
-- the articulation disorder group. Then all subjects with
articulation problems were tested on the revised Pea-
body picture vocabulary test and included in the study
if they had a-language quotient of 85 or greater. - --
All subjects were tested on the Quick Neurolog-
ical Screening Test, the Test of Motor Impairment,
_ and the Imitation of Postures test in the orderlisted.
The standardized procedures described in the respec-
tive test manuals were followed.
The mean and standard deviation for each of the
groups on the Quick Neurological Screening Test,
the Imitation of Postures test, and the Test of Motor
Impairment are shown on Table 1. Between-group
analyses were performed on the raw score of the
Quick Neurological Screening Test to determine if
the articulation disorder group presented more soft
neurological signs than the control group. Results
indicated a significantly greater number of soft neu-_
rological signs in the articulation disorder group [F
(1,28) = 10.24, p < .01].
In addition, scores on the Quick Neurological
Screening Test were categorized as normal or suspi-
cious o f having a dcificit by taking into account the
child's age and adjusting the raw score points accord-
ingly. When the age at which 50% of the normative
sample passed a specific item was greater than a
child's age, the score from this item was not included
in the raw score points to determine the category. For
example, children under 6 years of age are not ex-
pected to pass the palm form recognition test or the
sound patterns test; hence points from these two
items were not included when the raw scores were
categorized as normal or suspicious. In using this
method, all subjects in the control group were in the
normalcategory, 10 of the 15 subjects in the articu-
lation disorder group were in the normal category; 5
were in the suspiciotrs group. Using these data, the
Fisher Exact Probability Test was calculated with p =
Mean and Standard Deviation of Articulation Disorder
and Normal Control Subjects on Three Tests
Note. QNST = Quick Neurological Screening Test (Mutti, Sterling,
& Spalding, 1978); TMI = Test of Motor Impairment (Stott, Moyes
&Henderson. 1984); IP = Imitation of Postures test (Ayres, 1980b).
.02, showing a significant difference between the
.--:groups on .the-Quick.Neurological Screening Test
categories (p < .05).
Between-group analyses were performed on the
Imitation of Postures test scores. The between-group
difference was not significant [F (1,28) <I].
Between-group analyses were also performed on
---the number of errors on the Test of Motor Impair-
ment. The articulation disorder group made signifi-
cantly more errors than the control group [F (1,28) = -
---6.48;~ < .05]. In addition, scores on the Test of Motor
Impairment were categorized as normalor impaired.:
One subject of the 15 in the normal control group
scored in the impaired category on the Test of Motor
Impairment and 6 of the 15 subjects in the articulation
disorder group scored in the impaired category. The
Fisher Exact Probability Test was calculated with p =
Correlation coefficients were computed between
certain tests for the articulation disorder group. A
Pearson correlation coefficient was calculated for the
connected speech and Templin-Darley scores. The
correlation (r= -0.41) approached, but did not reach,
significance ( p < .lo). Similarly, a Pearson correlation
- -coefficient was computed between the Test of Motor
-Impairment points and the Imitation of Postures test
standard score. The correlation was not significant
The Interrater analysis was performed comparing
two speech therapists on three samples of connected
speech. They ranked the three samples in the same
order of severity, with differences between two of the
samples being 4%, and a difference of 14% (64% and
50%) on one sample.
The articulation disorder subjects displayed signifi-
cantly more soft neurological signs when assessed on
the Quick Neurological Screening Test than did their
normal peers. This is true despite the fact that the
Quick Neurological Screening Test is designed to
identify children at risk for learning disabilities and
none of the subjects were identified as having learn-
ing disabilities. Perhaps the younger, 5- and 6-year-
old children in this sample had not yet been identi-
fied. While the number of raw score points alone (not
adjusted for age) would have identified 30% of the
normal group as being in the suspiciozts range, and
80% of the children in the articulation disorder group
as being in the suspicious or deficit range, the use of
__-law score points LO categorize children as at risk for
learning disabilities at the younger ages is hazardous.
Although the test purports to be appropriate for chil-
dren 5 years old and older and uses the same cut-off
-- scores, an examination of the percentages of children
passing each item at the younger ages indicated that
at the 5-year-old level (5.0), 9 out of 15 items on the
Quick Neurological Screening Test are passed by less
than 50% of children at this age. A similar but less
marked problem exists for 6-year-olds.
- - - ----When-scores w-ere recalculated taking into ac-
count the age at which a child passed each item, five
of the articulation disorder subjects were still identi-
fied as being in the suspicious range. If the presence
of an articulation disorder coupled with soft neuro-
logical signs can be considered to represent devel-
----opmental apraxia of speech as is suggested by some
researchers (Kornse, Manni, & Rubenstein, 1981; Ro-
senbek & Wertz, 1972; Yoss & Darley, 1974),-then
-- --five of thechildren in the articulation disorder group
may be identified as having developmental apraxia of
speech. It is interesting to speculate that those sub-
jects with developmental apraxia of speech are more
likely to have developmental motor dyspraxia than
children with articulation problems without soft neu-
rological signs. Unfortunately, the number of subjects
in the current study was not large enough to examine
The difference between the articulation disorder
group and the control group on the Test of Motor
Impairment supports previous research, which indi-
cates that children with articulation problems do less
well on motor coordination tests than their peers
(Bilto, 1941; Jenkins Sr Lohr, 1964; Prins, 1962). How-
ever, two other studies did not support this type of
relationship (Aram & Horwitz, 1983; Reid, 1947). One
reason for these different findings may be the type of
test used. Studies have used different methods of
assessing articulation as well as different methods of
assessing motor coordination, thus limiting the accu-
racy that can be achieved by comparing studies. The
finding in this study that, in the articulation group,
there was no significant correlation between scores
on the Imitation of Postures test and scores on the
Test of Motor Impairment supports the suggestion
that the different motor tests used in the various
studies may be measuring different things. The Test
of Motor Impairment is a general test of motor coor-
dination while the Imitation of Postures test more
specifically assesses one type of motor planning abil-
ity. The children with articulation problems in this
study were not dyspraxic as a group, but they were
less well coordinated in general motor abilities than
The American Jorlr~~al o f Occr~pntiotzal Tberapjl
were their peers. The fact that this sample did not
include cl~lldrcn wlth identified learnlng disorders
may also- have influenced the results. The majority of
children with developmental dyspraxia appear also to
be learning disabled (Abbie, Douglas, 8i Ross, 1978;
Gubbay, 1975, 1979). Perhaps selection of an articu-
lation disorder sample with identified learning-d~s-
abled subjects would have presented different results.
An alternative explanation for the finding thaf chil-
dren with articulation problems were not dyspraxic
deals with the test used. Levine (1985) has suggested
that articulation deficits are more clearly related to
fine motor planning than gross motor planning. While
the Imitation of Postures test is considered the best
singleindicator of dyspraxia on the Southern Califor-
nia Sensory Integration Tests, It was designed to be
used in conjunction with an entire test group (Ayres,
1980b). Moreover, it assesses only one aspect of
praxis. Ayres (1985) has suggested that, because of
an underlying general cognitive or conceptual basis,
motor planning may be more clearly related to recep-
tive language than to expressive language. The new
Sensory Integration and Praxis Tests (Ayres, 1985)
---include six-different tests measuring elements of mo-
tor planning, including constructional praxis, praxis
to verbal command, graphic praxis, sequencing
praxis, and oral praxis, as well as the ability to imitate
postures. The use of a variety of tests of praxis will
provide more detailed information on the relation-
ship between dyspraxia and articulation problems.
Recently, in a sample of 182 children with known or
suspected sensory integrative dysfunction, Ayres and
Mailloux (1985) found a moderate correlation (r =
.42) between the Imitation of Postures test and the
Oral Praxis test, the new Sensory Integration and
Praxis test that most closely relates to oral dysp~asia
(Ayres, 1985). However, the associati011 bct\tfcen the
Oral Praxis test and a test of manual motor sequcnc.
- ing, the Sequencing Praxis test, was even higher (r =
.56), suggesting a general sequencing function com-
mon to both manual and oral tasks (Ayres, 1985; Ayres
8; Mailloux, 1985). The Oral Praxis test tras also
somewhat related to bilateral motor execution (hyres
8; Mailloux, 1985).
The relationship bet~veen the n~casurcs of artic-
ulation was examined in the articu1:ltion group. No
significmt correlation \vas found bct\vcen scores on
the Templin-Darley and the connected speech sam-
ples. Several subjects who did not score itnpaired on
one of these tests did score itrlpaired on the other,
and vice versa. Three subjects did not score impaired
on the Templin-Darlcy although their connected
speech scores demonstrated an error rate ranging
from 10% to 18%. The one subject who did not score
in the intpaired range on the connected speech sam-
ple had a standard deviation score of -3.9 on the
Templin-Darley. There are several reasons why the
two articulation tests did not highIy correlate with
each other. Some children can control their articula-
tion problem and correctly articulate single words in
a screening test such as the Templin-Darley although
they cannot control their articulation in connected
speech (Bernthal & Bankson, 1981). The subject who
scored well o n the connected speech sample and did
poorly on the Templin-Darley did so because, in the
.connected speech sample,~~sTe~-did
words containing sounds she commonly' misarticu-
. -1ated. One limitation of the connected speech sample
is the inability of the tape recorder to accurately
record misarticulated, high-frequency sibilant sounds,
such as the s sound, which is a frequently misarticu-
lated phoneme (Bernthal & Bankson, 1981). :.
- The results of this study have several implications
=--=-for occupational therapists.-Fir$,--the -relationship be--=
tween articulationproblemiTnd motor coordination
suggests that occupational therapy screening for mo-
---:-tor coordination -disorders -should be -considered .in--
children with articulation problems. Second,'occu-
pational therapy using sensory integration procedures
n6t use many-
~ - has been found to improve language in children with
sensory integration ' 'problems (Clark S r Steingold,
1982). While articulation is a speech disorder rather
.- . .. -
-_ __than a~1anguage::disorder;it maybethatif~he-articu-:.
!ation problems are found to be related to a motor.
planning disorder (with a somatosensory conceptual
base) when comprehensive manifestations of motor
planning are assessed, then sensory integration pro-
cedures may influence both motor dyspraxia and de-
velopmental apraxia of speech. Clark and Steingold
(1982) hive eloquently elaborated this rationale.
While controlled trials are necessary to validate this
approach to treatment, it is interesting to note that
some speech therapy treatment manuals for articula-
tion disorders include gross and fine motor activities
-- The authors thank Ellen Difantis;tlGprincipal, ihe-<eachers
and staff, and the panicip:~ting children of the Bridge School
in Lexington, Massachusetts, for their assistance in con-
ducting the study, and Dr. Nicholas Bankson of Boston
University's Sargent College for his assistance in designing
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o f edr~ca-
Cambridge, MA: Ed-