Improvement of fine motor skills in children with visual impairment: An explorative study

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Improvement of fine motor skills in children with visual impairment:
An explorative study
A.M. Reimer
a,
*, R.F.A. Cox
a,b
, M.W.G. Nijhuis-Van der Sanden
c
, F.N. Boonstra
a
a
Bartime
´us, Institute for the Visually Impaired, Zeist, The Netherlands
b
Behavioural Science Institute, Radboud University Nijmegen, The Netherlands
c
Radboud University Nijmegen Medical Centre, IQ Healthcare, The Netherlands
1. Introduction
1.1. Development of motor coordination and visual impairment
Visual information plays an essential and guiding role in the planning and execution of voluntary goal-directed
movements, especially during development and learning (Cox & Smitsman, 2006a,b; Reimer, Cox, Boonstra, & Smits-
Engelsman, 2008; Tro
¨ster, 1993; Von Hofsten, 2002).
The adaptive behaviour that enables us to maintain a fluent relation with our environment requires a continuous
informational link with this environment by means of direct sensory contact. This contact is effectuated by perceptual
subsystems, action subsystems, and in particular by their mutual dependence and development (Bushnell & Boudreau, 1993;
Von Hofsten, 2002). The visual system, in particular, is part of many perception–action couplings that allow us to meet the
complex demands coming from a dynamic surrounding. Perception–action couplings can loosely be defined as temporary
stable, softly assembled synergies between perception and action subsystems that are functional in specific action contexts
(Gibson, 1979; Turvey, 2007).
Children with visual impairment are partly or completely deficient in the input of one of the vital sensory subsystems. If
the visual information is incomplete or impoverish, the information necessary for action becomes more dependent on the
Research in Developmental Disabilities 32 (2011) 1924–1933
ARTICLE INFO
Article history:
Received 15 March 2011
Received in revised form 23 March 2011
Accepted 24 March 2011
Available online 30 April 2011
Keywords:
Visually impaired children
Visual attention
Fine-motor skills nystagmus
Ocular torticollis
Motor development
ABSTRACT
In this study we analysed the potential spin-off of magnifier training on the fine-motor
skills of visually impaired children. The fine-motor skills of 4- and 5-year-old visually
impaired children were assessed using the manual skills test for children (6–12 years)
with a visual impairment (ManuVis) and movement assessment for children (Movement
ABC), before and after receiving a 12-sessions training within a 6-weeks period. The
training was designed to practice the use of a stand magnifier, as part of a larger research
project on low-vision aids. In this study, fifteen children trained with a magnifier; seven
without. Sixteen children had nystagmus. In this group head orie ntation (ocular torticollis)
was monitored. Results showed an age-related progress in children’s fine-motor skills
after the training, irrespective of magnifier condition: performance speed of the ManuVis
items went from 333.4 s to 273.6 s on average. Accu racy in the writing tasks also increased.
Finally, for the children with nystagmus, an increase of ocular torticollis was found. These
results suggest a careful reconsideration of which intervention is most effective for
enhancing perceptuomotor performance in visually impaired children: specific ‘fine-
motor’ training or ‘non-specific’ visual-attention training with a magnifier.
ß2011 Elsevier Ltd. All rights reserved.
* Corresponding author at: Bartime
´us, P.O. Box 1003, 3700 BA Zeist, The Netherlands. Tel.: +31 30 6982462.
E-mail addresses: areimer@bartimeus.nl,a.m.reimer@xs4all.nl (A.M. Reimer).
Contents lists available at ScienceDirect
Research in Developmental Disabilities
0891-4222/$ – see front matter ß2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2011.03.023

remaining senses, and, as a result, behaviour often becomes less effective and efficient. Recently, it has been shown that there
are specific differences in sensorimotor control between children with visual impairment and children with normal vision
(Reimer et al., 2008). Interestingly, these differences were not all caused directly by the poorer vision per se, but seem to
result from poorer calibration of the sensory information necessary for task performance. Various aspects of children’s every-
day behaviour (e.g. goal-directed movements and spatial orientation), as well as the general cognitive and social/emotional
development, are negatively influenced by this condition (Tro
¨ster, 1993).
The motor development of children with low vision is qualitatively and quantitatively different compared to children
with normal vision. This is true for both the fine-motor skills as well as for their gross motor abilities (Helders, 1982;
Houwen, Visscher, Lemmink, & Hartman, 2008; Norris, Spaulding, & Brodie, 1957; Tro
¨ster, 1993; Vervloed, 1996). First and
foremost, visual impairment has a negative influence on their general motor activity, and may lead to developmental delays.
The impact of visual impairment is different for each phase in the development: motor milestones are generally reached later
and are sometimes even traversed in a different order. The functional development in terms of the action repertoire (i.e., the
capability for solving action problems) also shows impairment-specific trajectories in children with visual impairment. The
size and shape of the deviation from normative development depends, amongst other things, on the cause and severity of the
child’s visual impairment (anamnesis), in ways that are largely unknown (Brambring, 2001; Houwen et al., 2008).
Children with visual impairment experience uncertainty and insecurity with respect to the position and movements of
their own body in space, of their own limbs with respect to their body, and of other people and objects in a room. This
deficient spatial connection has a detrimental effect on the development of important gross-motor qualities such as
adequate postural stability and control (e.g. sitting and standing), as well as on the acquisition of different modes of
locomotion (e.g. crawling and walking) (Palazesi, 1986). In addition to this, it takes them more effort to complete tasks
involving fine-motor skills, such as object manipulation, object-oriented play and tool use. In a comparison study on the fine
motor skills in children with visual impairment, aged six to ten, it was found that the performance was slower and more at
one side of the body than in children with normal vision (Smits-Engelsman, Reimer, & Siemonsma-Boom, 2003).
The developmental delays with respect to gross-motor skills and fine-motor skills might be related, because the former
provide a stable platform for the development of the latter. For instance, stable erect sitting elicits a cascade of
developmental processes with respect to reaching and grasping in young children, simply because the arms become
available for actions at a larger radius, especially of importance when visual information is reduced (Bertenthal & Von
Hofsten, 1998; Out, Van Soest, Savelsbergh, & Hopkins, 1998; Savelsbergh & van der Kamp, 1994). This makes it possible to
grasp nearby objects and touch surrounding surfaces, in order to actively explore them and perhaps employ them in the
pursuit of more distal action goals. However, children with low vision are at risk for insufficient development of their fine-
motor skills and eye-hand coordination for more direct reasons as well (Bouchard & Tetreault, 2000; Johansson, Westling,
Backstrom, & Flanagan, 2001). An important drawback is that, because of their poorer eyesight, these children often lack the
intrinsic motivation to explore small objects and are less aware of, and as a result show little interest in, the detail-
information that things possess (Cox et al., 2009). This, of course, has a negative effect on the amount of time they spend on
performing fine-motor activities typically associated with exploration and manipulation of objects, compared to their
normally sighted peers.
1.2. Ocular torticollis
Congenital nystagmus (CN) has been described as a ‘fixation’ nystagmus, implying an inability to fixate a visual target on
the fovea. However, each cycle of CN contains a target-foveation period during which the eye movement velocity is lowest.
Prolongation of foveation time, reduction of retinal image velocity and cycle-to-cycle foveation repeatability all contribute to
increased visual acuity (Dell’Osso, van der Steen, Steinman, & Collewijn, 1992a, 1992b). With CN fixation of a target is
difficult, which complicates the accuracy with which fine-motor tasks can be performed (Stevens & Hertle, 2003). Despite
some claims that CN is caused by absent or ‘reversed’ smooth pursuit, people with CN hardly ever experience oscillopsia or
exhibit any accompanying symptoms of such deficits in pursuit. They are able to master sports requiring tracking of rapidly
moving small objects (e.g. racquetball or handball) (Dell’Osso et al., 1992b).
A large number of children with visual impairment have nystagmus, which result at the behavioural levelin strategies or
adaptation mechanisms in order to decrease the lack of foveation possibilities (Abadi & Bjerre, 2002; Rubin & Wagner,
1986; Stevens & Hertle, 2003). So as a coping mechanism, children with nystagmus may develop a functional head posture,
referred to as ocular torticolles (Abadi & Bjerre, 2002; Rubin & Wagner, 1986) which diminishes the negative effects of these
tremor-like eye-movements. The direction of gaze with minimal nystagmus is called the neutral zone, which is the gaze
direction that is preferred by the child (Dell’Osso et al., 1992a, 1992b). If this neutral zone is while looking straight ahead,
the child does not turn his or her head. If the neutral zone is eccentric, a compensatory head-turn position is taken (i.e.
ocular torticollis), in order to enforce as less nystagmus as possible, fixating with the eyes in the neutral zone (Kommerell,
1986).
Ocular torticollis, therefore, denotes the tendency to keep the head in an oblique orientation during the performance of
visually demanding activities. This is, for instance, observable in tasks with high-accuracy constraints or demands such as
writing, or performing the items of a fine-motor test for that matter. It is unknown when children with nystagmus start
developing this ocular torticollis. In the care of visually impaired children it is often assumed that children develop ocular
torticollis when they go to school. At that time, performing high-precision tasks becomes a more prominent part of the daily
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routine of children. In any case, it is reasonable to suspect that there is a causal, or at least a temporal, relation between the
onset of ocular torticollis and the demands on fine-motor skills.
1.3. Earlier study: magnifier training
The present study is part of a research project funded by the Netherlands Organisation for Health Research and
Development (ZonMw, program InZicht). The larger research project was a study with matched groups (matched on visual
acuity and age), with the purpose of investigating the effectiveness of training with a stand magnifier in young children with
a visual impairment. The results of this experimental part of the research project (i.e., on the effectiveness of the magnifier
training) were reported elsewhere (Cox et al., 2009; Cox, Reimer, Verezen, Vervloed, & Boonstra, 2007). Below a concise
description of the main features of the experimental design and training will be given, so as to give the reader an idea of its
rationale, set-up and main results.
The training that was especially developed for this project involved 12 half-hour sessions within a six-week period. All
training sessions were performed under the supervision of a personal trainer who instructed, guided and motivated the child
in his/her performance of the task. The training material consisted of eight different A3-sized (42 cm 29.7 cm) sheets, each
with four trails of small symbols printed on them. An example of one such sheet that was used in the training is shown in
Fig. 1a. The trails crossed each other several times. Their orientation varied on different sheets (horizontal, vertical and
circular), so as to induce trail-following movements in different directions. Each trail consisted of one specific type of small
symbol from the LEA-optotype set (Hyvarinen, Nasanen, & Laurinen, 1980). The LEA-optotypes are four symbols (heart,
circle, house and square) they have been described and standardized for visual acuity testing in children (Hyvarinen, 1995).
Children were instructed to follow the trails meticulously, from a picture that marked its beginning to a corresponding
picture marking its end. Half of the participating children trained with a stand magnifier (Fig. 1b), whereas the other half
used no visual aid (but instead used their finger to follow the trail during the training). Both groups performed the same task
however, and had an equal number of training sessions. The effectiveness of the training with respect to magnifier use was
assessed in a pre-test/post-test design. All children used the stand magnifier in the pre-test and post-test, in which they
performed a similar trail-following task as during the training. The size of the symbols used in the training and pre and post
tests was individually scaled, that is, based on each child’s individual threshold M-value at a self chosen distance near visual
acuity, as determined with a standard test (Hyvarinen, 1995). If a magnifier was used (i.e. in the pre-test and post-test for all
children and in half of the group during the training), the symbol size (M-value) was three logmar units below the child’s
threshold near visual acuity, making the use of the magnifier crucial for accurate task performance. If no magnifier was used
(i.e., in half of the group during the training), the symbol size was precisely at the child’s threshold M-value. Setting the
symbol size for each child individually in this way ensured that performing the task was similarly demanding and difficult for
[()TD$FIG]
Fig. 1. Materials used in the magnifier training. (a) An example A3-sheet with four horizontally orientated trials of LEA-symbols. (b) The stand magnifier
used in the study.
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all children, in both training groups. In other words, it required much visual attention and concentration, regardless of
threshold M-value, and regardless of whether you trained with or without the magnifier.
The results of thestudy showed an overall improvement of task performance across all children after the training (Cox et al.,
2009, 2007). For the group that trained with the magnifier the quality of task performance, as measured by the number of
correctly followed trails (i.e. correctly found pictures at the end), increased more compared tothe (control) group that trained
without the magnifier. Importantly, the results of the study demonstrated that all children benefitted from the training.
1.4. The present study
In the context of the larger research project described above, children’s fine-motor skills were assessed using standard
instruments for manual dexterity in visually impaired children, i.e. the ManuVis (Smits-Engelsman et al., 2003) and the
writing task of the Movement ABC (Henderson & Sugden, 1992). In order to enable us to detect a potential spin-off effect of
the training on fine motor skills we decided to administer the test items twice; at the pre-test as well as at the post-test.
Although we have not measured a control group that received no training at all, some general conclusions and interesting
observations might still be possible. In the present paper the results of this repeated measurement of fine-motor skills in the
participating four- and five-year-old children with visual impairment are reported for the first time. It is important to
emphasize again that the training was non-specific with respect to the majority of items in the fine-motor tests, but
nevertheless entailed an intensive and demanding visual-attention task.
Due to the intensive character of the training with respect to visual attention and eye-hand coordination, we expected an
improvement in the performance of the fine-motor tests, as well as an increase in ocular torticollis in the children with
nystagmus, in both training groups. There is no clear basis to expect differences between the training groups (i.e. with
magnifier versus with finger), since the training is designed to be equally demanding in both groups.
2. Method
2.1. Subjects
A group of 8 girls and 14 boys participated in this study. They were assigned to one of the two experimental trainings
groups, with or without magnifier (see Table 1). There were 15 (68%) 4-year-old children (10 boys and 5 girls) and 7 (32%) 5-
year old children (4 boys and 3 girls). All children were visually impaired, and were selected on the basis of having a near
visual acuity between 0.05 and 0.3 (Snellen equivalent: 20/400–20/67) (Hyvarinen, 1995). Exclusion criteria were
progressive eye disease, hemianopia, mental retardation, prematurity, dysmaturity, perinatal complications or delay in
motor development. Nystagmus was present in a total of 16 of the included children (see Table 1).
Finally, the inclusion criteria required children to have a developmental level in accordance with the age-norms for this
group, so as to ensure that children were able to understand the task and the instructions. This was assessed using the
Reynell–Zinkin Development Scale for Young Visually Handicapped Children (Reynell, 1979).
Table 1
Data of 22 children concerning diagnosis, age, sex, training (with or without magnifier), visual acuity, motometric and motoscopic data.
Item 1-5 ManuVis (s) Motoscopic data
Child number Diagnosis Age Sex Training group Visual acuity Pre-test Post-test Pre-test Post-test
1 Achromatopsia 4:01 F With 20/80 356 242 14% 42%
2 Albinism 4:00 M With 20/100 360 312 16% 19%
3 Albinism 4:04 M With 20/200 254 276 20% 35%
4 Albinism 4:06 M With 20/200 302 227 44% 49%
5 Albinism 5:01 M With 20/100 371 331 * *
6 Albinism 5:03 M With 20/200 296 256 24% 47%
7 Albinism 5:06 M With 20/200 231 231 32% 43%
8 Cong cataract 4:07 F With 20/200 285 321 20% 19%
9 Cong cataract 5:11 F With 20/60 248 199 7% 48%
10 Cong nystagmus 4:02 M With 20/60 399 330 12% 43%
11 Cong nystagmus 4:05 M With 20/100 346 269 22% 43%
12 Cong nystagmus 4:10 M With 20/100 197 184 34% 46%
13 Retinoschizis 5:07 F With 20/60 285 260 27% 34%
14 Albinism 4:03 F Without 20/200 426 327 21% 6%
15 Albinism 5:11 F Without 20/200 235 245 26% 42%
16 Retinoschizis 4:10 M Without 20/120 233 267 6% 12%
18 Cong cataract 4:06 F With 20/60 231 227
21 Retinoblastoma 4:05 F With 20/270 317 209
17 Cong cataract 4:08 M Without 20/60 516 355
19 Hypermetropia 4:00 M Without 20/60 586 331
20 Moebius 4:07 M Without 20/50 539 408
22 Retinoschizis 5:10 M Without 20/100 321 206
Data for participant 5 is missing because of technical videotape problems.
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2.2. Material, design and procedure
In this study children performed the bicycle trail test of the Dutch version of the Movement ABC (Henderson & Sugden,
1992) and the complete ManuVis test (Smits-Engelsman et al., 2003) twice. The tests were administered by or under the
supervision of an experienced professional paediatric physical therapist. The validity and reliability of the Movement ABC
were established by Henderson and Sugden (1992). The Dutch version of the Movement ABC showed no differences in norm
scores with the original norm scores (Smits Engelsman, 1998). The ManuVis is especially developed to measure and quantify
manual dexterity of children with visual impairment in the age range of 6–12 years. This test is also proven valid and reliable,
and has norm scores for this age range.
The fine-motor items of the ManuVis provide quantitative measurements of different aspects of motor behaviour for each
test item separately (i.e. motometric data), and produce an overall score for each individual child when combined. The
writing task of the ManuVis also measures movement speed, whereas the writing tasks of both ManuVis and Movement ABC
allow for the assessment of the quality of performance.
Below a description of the individual items of the tests will be given: there are two unimanual items, three bimanual
items, and two items for eye-hand coordination. A picture of all the material used in the tests is shown in Fig. 2.
In addition, for each item, children’s head orientation and working distance (motoscopic data) was scored. These aspects
of task-related behaviour were chosen for their relevance in visually impaired children (Kommerell, 1986). Details of this
scoring are also described below. All scoring was done from the videotaped sessions.
2.2.1. Unimanual items
Putting coins in a moneybox. Ten coins are presented in an open container, so that their starting position is relatively fixed,
and have to be picked up one-by-one and pushed into the slit of a moneybox. The task is carried out with both the left and the
right hand separately, starting with the child’s preferred hand.
Putting rings on rods. Twelve wooden rings must be placed on three vertical round rods, standing side-by-side. The rings
are positioned on a wooden board in three columns of four rings, right in front of the rods. The task is to place the first ring on
the first rod (on the left), the second one on the middle rod, the third on the right rod, and so on, starting with the left rod
again and continuing in the same order. The rings may be picked up in any order. This task is also performed with the left
hand and the right hand, starting with the preferred one.
2.2.2. Bimanual items
Screwing nuts on bolt. Two nuts must be attached on a bolt (nut: 1 cm in diameter; bolt: 3 cm long) using a sort of counter-
movement of the hands, and then screwed on using fingers and thumbs. The bolt is kept in one hand, while the nut is in the
other hand.
Threading beads. Six octagonal beads (1.2 cm in diameter and 1.5 cm long) in an open container must be threaded onto a
piece of cord of approximately 38 cm. The beads must be picked up one at the time, and the cord’s end must be carefully
manipulated into the opening and shoved through completely.
Threading lace. A 40 cm long (shoe)lace is attached to the back of a wooden board (22 cm by 3 cm, and 3 mm thick). The
lace must be threaded through each consecutive hole in the board, from the back to the front and back again. So, when the
lace comes out through the hole on one side, it must be pushed back through again to the other side at the immediate next
hole. There must be no loops over the edge of the board.
[()TD$FIG]
Fig. 2. Materials used in the ManuVis and the Movement ABC: (1) money box, (2) wooden board with twelve rings, (3) nuts with bolt, (4) beads with cord, (5)
board with lace, (6) open container, and (7) the two papers for the writing tasks.
A.M. Reimer et al. / Research in Developmental Disabilities 32 (2011) 1924–1933
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2.2.3. Eye-hand coordination items
Drawing dots (ManuVis). This item requires children to carefully place dots with a felt-tip pen in small circles. There are 32
circles on a trail from the left-side to the right-side of an A4-sized paper. This item has been designed to measure eye-hand
coordination, which constitutes an obvious difficulty for visually impaired children. The task quantifies the relative degree of
success and difficulty of this type of coordination, by counting the correct dots and the speed.
Bicycle trail (Movement ABC). Here children have to draw a single continuous line on a track, without crossing the
delineations. The track is approximately 33 cm long and 0.4cm broad, and has four alterations of movement direction; two
right angles and two round curves. When the pen is lifted up from the paper, the child is allowed to continue from the same
point. The paper may be rotated up to 45 degrees with respect to the edge of the table, so as to facilitate task performance.
Number of crossings of the delineations is scored afterwards from the drawing, and speed is recorded as well.
2.2.4. Motoscopic (quality of movements) measurement
Working distance. Children’s overall working distance was scored during the performance of each of the five fine-motor
items. During the one-handed items the child was not allowed to lift part of the material. She could get closer, however, by
bending forward. During the two-handed items the child could lift all the material, in order to bring it closer to the eyes. Since
it was not possible to reliably score working distance in centimetres, scoring was done categorically. The following categories
were used: (a) larger than 20 cm, (b) 20–15 cm, (c) 15–10 cm, (d) 10 cm–5 cm, and (e) less than 5 cm.
Ocular torticollis. Children’s head orientations of 15 children were scored at critical instances (see below) during task
performance. This was done for each of the five fine-motor items of the ManuVis, during both the pre-test and post-test
measurement. For the two unimanual items the head orientation was scored for each hand separately. An observer scored
whether the head was not on the midline (i.e. upright) for at least two seconds, so whether the head was either rotated or in
lateroflexion (both more than 10 degrees). Lateroflexion is defined as the situation where one eye is above a certain
horizontal line whereas the other eye is below that same line. Rotation is defined as the situation where the nose is left or
right of the body midline.
The critical instances were pre-defined as those moments during each particular item where visual control was essential
for adequate task performance: when a ring was placed on a rod (2 hands; 12 rings each), when a coin was put in the
moneybox (2 hands; 10 coins each), when the bead was pushed on the cord (6 beads), when the lace was pushed in the gap of
the board (6 gaps), and at the start and finish (2) of connecting the nuts onto the bolt (2 nuts). The maximum possible score of
‘ocular torticollis’ was 60.
2.3. Scoring and data analysis
For the motoscopic measures, 20% of video-recordings were observed by two scorers. The inter-rater reliability was at
least 0.8 of each item. Preliminary analysis has shown no differences in task performance between the sexes, and the data
for girls and boys have therefore been pooled in what follows. All the data were analysed in the statistical program SPSS
(Version 16.0). Correlation analyses of variance and t-tests were performed on the data, using a significance level (alpha)
of .05.
3. Results
Below we will subsequently report performance measures and statistical analyses of (1) the quantitative data of the
ManuVis, (2) the writing tasks of the Movement ABC and ManuVis, and (3) the motoscopic data (i.e. working distance and
ocular torticollis) during the execution of the items.
3.1. Motometric data: ManuVis
In this section the analyses of the five fine-motor items of the ManuVis will be presented for the pre-test and the post-
test. The main performance measure is the time (i.e. duration in seconds) a child needed to finish the test items,
individually and combined (Smits-Engelsman et al., 2003). A lower duration score corresponds to a higher item
performance speed, which requires more developed fine-motor skills, and vice versa. An overview of the total-test
duration score for each child (raw data; see below) as well as additional subject data is presented in Table 1,forboth
measurement instances separately.
The mean performance duration for each individual test item, of all children and for the children with versus without
magnifier, are presented in Table 2, for the two phases in the original study.
1
Table 3 displays the correlations between item
durations: The upper-right part for the pre-test and the lower-left part for the post-test.
1
Due to a procedural error in the execution of the item ‘screwing nuts on bolt’ made by one of the testers during the post-test, a recalculation was
necessary for 36% of the scores (i.e. eight children). The analysis presented here are with the recalculated durations for this particular item. However, when
the scores for this item are excluded from the analysis, this does not lead to differences in the reported results. The total score in the pre-test without this
item was 277.1 s versus a total score in the post-test of 229.5 s.
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A one-factor (training group: with versus without magnifier) multivariate analysis of variance was performed on the
durations scores of all five fine-motor skill items of the ManuVis, with age in months as a covariate.
2
This yielded a significant
main effect, F(5,15) = 4.31, p= .012 (Wilk’s lambda = 0.41), revealing a difference in total score on the ManuVis between the
children who had trained with the magnifier compared to those who had trained without magnifier. None of the individual
items were significantly different between the groups, with a Bonferroni corrected alpha-level. The same analysis performed
on the item durations in the pre-test did not yield a significant difference between the groups, revealing that performance
differences were not present before the start of the training.
3.2. Total score of the ManuVis: age differences
The total score for the fine-motor skills part of the ManuVis for each child is given by the sum of his/her duration scores on
the five individual items. This total performance duration constitutes the main measure of this assessment instrument, for
which norm-scores are reported in the age range of 6- to 12-year-old children (Smits-Engelsman et al., 2003). Fig. 3 presents
the mean total scores, that is, the total performance duration of all fine-motor items together, for the two age groups in this
study.
Table 2
Mean scores (mean times in seconds (SD)) for each item of the ManuVis and the eye-hand coordination tasks of ManuVis and movement ABC.
Item Total pre-test Post-test Without magnifier pre-test Post-test With magnifier pre-test Post-test
Threading beads 73.6 (36.2) 59.5 (19.7) 87.1 (48.3) 69.8 (20.5) 64.2 (22.4) 52.5 (16.2)
Putting coins in moneybox 51.4 (11.8) 49.1 (7.6) 51.0 (12.2) 53.1 (7.5) 51.6 (11.9) 46.4 (6.7)
Putting rings on rods 71.6 (26.1) 60.0 (11.5) 82.89 (36.8) 59.0 (11.0) 63.7 (11.3) 60.7 (12.2)
Threading lace 73.1 (45.4) 57.0 (22.9) 97.4 (54.7) 68.9 (22.2) 56.2 (29.3) 48.7 (20.2)
Screwing nuts on bolt 63.7 (23.6) 47.7 (17.5) 62.2 (16) 51.4 (15.9) 64.7 (28.2) 45.08 (18.7)
Item 1–5 combined 333.4 (105.9) 273.3 (58.5) 380.7 (138) 302.2 (62.6) 300.6 (63.9) 253.3 (48.2)
Writing tasks
ManuVis duration 94.0 (47.4) 70.5 (21.7) 106.6 (65.8) 66.7 (19.5) 83.5 (6.7) 73.3 (23.6)
ManuVis correct dots 6.4 (7.0) 12.6 (8.0) 5.9 (5.0) 6.7 (8.2) 12 (5.4) 13.1 (9.5
Movement abc score 2.3 (1.9) 0.9 (1.2) 3.2 (2.1) 0.89 (1.2) 1.7 (1.5) 0.85 (1.2)
[()TD$FIG]
Fig. 3. Graphical presentation of the mean total duration scores (mean times in seconds) of the fine-motor items of the ManuVis for different age groups. The
data-points of the 6-, 7-, and 8-year-olds are published norm-scores (Smits-Engelsman et al., 2003). The double data-points of the 4- and 5-year-olds come
from the present study.
Table 3
Correlations between the duration scores (performance measure) on all fine-motor items in the ManuVis: the upper-right part shows the correlations in the
pre-test phase, the lower-left part those for the post-test (cursive).
Item Threading beads Putting coins in moneybox Putting rings on rods Threading lace Screwing nuts on bolt
Threading beads – .58
**
.56
**
.65
**
.37
Putting coins in moneybox .57
**
– .06 .36 .32
Putting rings on rods .40 .44
*
– .40 .13
Threading lace .43
*
.53
*
.40 – .20
Screwing nuts on bolt .49
*
.45
*
.24 .32 –
*
p<.05.
**
p<.01.
2
Although group sizes were rather small and unequal, this analysis seems to be the appropriate one. A check of Box’s M test revealed that the covariance
matrices were equal for the dependent variables for the two groups.
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1930

From Fig. 3 at least two interesting observations can be made. First, during the pre-test, older children were faster in
performing the fine-motor items of the ManuVis than younger children (283.9 s versus 356.5 s, respectively; t(20) = 2.02,
p= .058). This pre-test difference is to be expected since the instrument is devised to assess fine-motor skills in (young)
children and monitors its changes on a developmental timescale in terms of the increase on this duration measure.
Unfortunately, norm-scores for four- and five-year-olds are not reported in the literature yet. Extrapolating from the
published norm-scores for older children however, we feel confident that pre-test performance of the younger children in
the present study is certainly reasonable and reliable.
The difference in performance duration between older and younger children is no longer present in the post-test (246.9 s
versus 285.7 s, respectively; t(20) = 1.49, p= .152). This relates to the second observation, which is that of a large reduction in
performance duration in both the four-year-olds (70.8 s or 19.9%) compared to five-year-olds (37.0 s or 13.0%). Both age
groups are faster after the training, F(1,20) = 11.20, p<.003, and the progress seems slightly larger in the younger group.
3.3. Eye-hand coordination: writing tasks
In what follows we will report the analysis on the data of the two eye-hand coordination tasks performed in this study:
the drawing of dots belonging to the ManuVis and the bicycle trial of the Movement ABC. Similar to the motometric data
above, before analyzing the writing data some corrections are necessary in case of errors made by the child during task
performance, which will be described below. Several different (corrected) results related to these items are given in Table 2,
for each of the two measurement instances.
3.3.1. Drawing dots (ManuVis)
The time children needed from drawing the first dot to the last one was recorded. For each mistake, a penalty addition was
made to the duration score, according to ManuVis instructions (speed-accuracy trade-off factor; (Smits-Engelsman et al.,
2003)). After these corrections, there proved to be a significant overall difference in item performance duration between the
pre-test and post-test, according to a paired-samples t-test, t(21) = 2.47, p= .023. Another measure of performance for this
item is the accuracy score, which is given by the amount of correctly placed dots (i.e. exactly within the small circle; from a
total of 32), and which increased after training, t(21) = 3.49, p= .002. For both measures there was no difference between
the age groups or between the training groups.
3.3.2. Bicycle trail (MABC)
The prominent measure for this item is the computed error score (see Movement ABC manual (Henderson & Sugden,
1992)). Children received a score between 0 and 5, where ‘0’ is given for perfect task performance and ‘5’ when he/she
completely failed to perform the task. The error score for the bicycle trail was significantly lower in the post-test than in the
pre-test, t(21) = 3.42, p= .003. In addition to this, the time it took children to complete the bicycle trail, also decreased
significantly, t(21) = 3.39, p= .003. Finally, as converging evidence of the fact that task performance has improved, we note
that the mean distance over the delineation went from 4.6 cm in the pre-test to 2.0 cm in the post-test, and the mean number
of occasions that the trail continued for 12 mm outside the delineation went from 1.4 to 0.5, in the pre-test and post-test,
respectively. Both are an indication of increased accuracy of task performance. Again no differences were found between
groups.
3.4. Motoscopic data
The motoscopic data gathered in this study consisted of the (overall) working distance and the (accumulated) head turns
during the five fine-motor items, recorded both in the pre-test and in the post-test. Results for working distance will include
all 22 children; head orientation only the 15 children with nystagmus.
3.4.1. Working distance
The overall working distance, averaged over all children and over all fine-motor items, showed a slight increase between
the pre-test en post-test, t(15) = 3.16, p= .006. This means working distance during the pre-test was 16.4 and 18.9 cm during
the post-test. Interestingly, there was no correlation between the mean working distance and the total score of the ManuVis.
Furthermore, none of the individual fine-motor items showed an increase or decrease in working distance after the training.
3.4.2. Ocular torticollis
The results of the head-orientation scores in the nystagmus group are presented in Table 1. Within this group, the amount
of ocular torticollis at critical instances in the task had increased significantly after the training, t(10) = 5.11, p<.000. The
mean scores, of a maximum of 60, were 21.8 (36.3%) and 40.9 (68.2%), for the pre-test and post-test, respectively.
4. Discussion
The purpose of this study was to investigate the potential enhancement of fine-motor skills in young children with visual
impairment after twelve sessions (six weeks) of intensive visual training. This training was carried out in the context of a
A.M. Reimer et al. / Research in Developmental Disabilities 32 (2011) 1924–1933
1931

larger research project. The training was especially designed to acquire and practice magnifier-using skills by means of a
trail-following task. As has been reported elsewhere (Cox et al., 2009), the training yielded a considerable improvement of
children’s skills and willingness to use a stand magnifier, and to engage in a demanding visual attention task. The results
reported in the present paper reveal a parallel improvement in children’s fine-motor skills due to the training (regardless of
using a magnifier) as demonstrated by significant overall increases in performance speed and accuracy across items in the
tests. In addition, during the post-test the children with nystagmus more often preferred to keep their head in an oblique
orientation. This phenomenon called ocular torticollis entailed that they increased the number of head turns at critical
instances during task performance, in order to utilize the neutral zone to acquire optimal fixation.
Regarding the possible mechanisms that might have contributed to the progress in fine-motor skills, it is hard to be very
precise and specific. No definite statements are warranted, since no experimental manipulations were carried out for this
purpose (except for the magnifier training, which was not specifically a training in fine motor skills) and the sample was too
small to construct groups based on child-related factors (only partly for nystagmus). However, the prominent role of visual
attention as discussed in the previous section clearly points in the direction of perceptuomotor processes underlying manual
control. In an earlier study of our research group we have put forward the idea of an impoverished integration and calibration
of sensory and motor subsystems in visually impaired children (Reimer et al., 2008). Accordingly, this group experiences
disadvantages in the coupling of executed (finger) movements and the visual and proprioceptive feedback coming from that.
Given that the training provided a large amount of experience with respect to the coupling of sensorimotor information, this
might have triggered a catch up in their learning. The precise underlying mechanisms by which this catch up was established
deserve further investigation, which should focus on selecting specific subgroups of children and designing experimental
manipulation based on relevant aspects of the task.
With respect to the intervention goal, it is well-known that children with low vision generally display different
developmental pathways with respect to fine-motor skills, compared to normally sighted peers.Still, to our knowledge there
are no evidence-based training or intervention programs that aim at targeting these particular problems in the low-vision
group. Amongst other things, this hiatus reflects a lack of knowledge about which kind of intervention is most suitable for
improving manual dexterity in visually impaired children. Professional therapists and researchers in the field must determine
which perceptual-motor training is mostadequate for this group: Specific trainingof fine-motor skills or non-specific (i.e. with
respect to fine-motorskills) visual attention training. The results of the present study make an interesting and compelling case
in support of the latter. Further investigation of different types of training and their combination is needed however.
To continue, the overall goal of vision training for children with visual impairment is to maximize the use of available
(residual) vision so as to promote optimal development of cognitive, motor, communicative and social functioning (Lueck
and Heinze, 2005). As mentioned in Section 1, in general, these children need to be motivated and stimulated to actively
explore their environment for attaining sensory (visual) information and to engage in fine-motor activities. This stimulation
at an early age is very important and has a positive effect on the development of fine-motor skills (Schellingerhout,
Smitsman, & Cox, 2005; Schellingerhout, Smitsman, & van Galen, 1997). Unless delays are detected and treated at an early
age, the resulting problems in many cases are permanent. The positive outcomes of low-vision aid training for children with
visual impairment are a novel feature in this field, serving two related but separate goals: improvement of magnifier-using
skills and fine-motor skills.
Additionally, in this context, it is important to know whether a visual-impaired child is functioning at a satisfactory level
or whether the child is delayed, compared to normally sighted peers as well as to visually impaired peers. Since children with
visual impairment are at greater risk of less-than-optimum development of manual dexterity, it is essential to monitor these
children during their development and to record their performance regularly, starting at a young age, using an objective and
standardized measuring instrument. If development is delayed, the availability of a specific measuring instrument can help
in the planning and evaluation of early intervention strategies for these children. It is therefore essential to develop an
assessment instrument especially for very young children with low vision. Such an instrument and corresponding age-
norms are currently lacking.
A major weakness of the present study is the rather small sample size. Although the results are significant and clear,
generalization to the entire population of visually impaired children is difficult. There was no control group (i.e. with no
training at all), because of the limited availability of children in this target group. Further investigation, of the development of
ocular torticollis in a larger sample of visually impaired children would be valuable, for instance. The same is true for an
explicit comparison of the motoscopic data during fine-motor tasks between children with and without nystagmus.
Another weakness of this study is the absence of norm-scores of the ManuVis for children of four and five years old.
However, as can be seen in Fig. 3, the present results of total duration scores during the pre-test measurement nicely
extrapolate from the published norm-scores for six- to eight-year-olds. In addition, in a manuscript from our research group
that is currently in preparation (Reimer et al., in preparation), norm-scores for the ManuVis will be reported for children in
the age of four years and five years. The total duration scores reported here are also perfectly in line with the data already
gathered for that study. Moreover, notwithstanding the current absence of norm-scores, children in this study have made an
exceptional and unexpectedly large progress with respect to their fine motor skills. This positive spin-off effect of the
training on fine-motor skills in this group of four- and-five-year-olds is remarkable, since the focus of the training was on
magnifier use and not on aspects of manual dexterity specifically. Considering these facts, it is likely that this leap is related
to the training that was done in this period, rather than being (completely) caused by natural development. Developmental
impact is present of course, but after a training period of six weeks there was more progress than is to be expected.
A.M. Reimer et al. / Research in Developmental Disabilities 32 (2011) 1924–1933
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Finally, our results emphasize the importance of visual attention and eye-hand coordination with respect to manual
dexterity, and how the former can serve as a vehicle to boost the development of the latter. A recent study with
kindergarteners also stresses this interaction between perceptual-motor development and attention development in young
children in a different way (Stewart, Rule, & Giordano, 2007). In that study, researchers found a relationship in the other
direction (i.e. fine-motor activities help increase attention), in a slightly older group of normally sighted children (six-year-
olds), and particularly in girls. Still, a relation between (visual) attention and fine-motor skills seems to be present in both
studies, which offers an interesting and promising direction for future research as well as for the development of
interventions.
Acknowledgements
The authors wish to express their appreciation to the following people for their assistance in the project: Tinie Bierman,
Loukie de Vaere, Froukje Zuidema, and Judith Holland. We also would like to thank all the students, trainers, and of course
the children and parents that participated in this project, for their considerable efforts.
This research was funded by the Netherlands Organisation for Health Research and Development (ZonMw, program
InZicht), project number 94303020.
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