Anomahes of Motor Development

in Hyperactive Boys
Martha Bridge Denckla, MD, and Rita G. Rudel, P h D

Forty-eight boys who scored high o n rating scales for the “hyperactive syndrome” but who went without traditional
neurological signs of learning disabilities were compared with 50 control boys on coordination tests. Discriminant
function scoresfor speed, rhythm, and overflow correctly classified 89% of the boys as those with“hyperactive”versus
“normal” behavioral histories. Thus, neurological examination of “hyperactive” boys does reveal developmentally
immature coordination.
Denckla MB, Rudel RG: Anomalies of motor development in hyperactive boys. Ann Neurol 3:231-233, 1978

Is the neurological examination of t h e child referred (M. B. D.). The general population from which these pa-
for hyperactivity useful?W e n d e r [ 141and Schain [ 111 tients were drawn is white, middle-class, and suburban, and
expressed skepticism about t h e contribution of tra- the sources of referral were school child-study teams (50%)
ditional neurological examination to the diagnosis of and pediatricians, child psychiatrists, or both (50%). The
senior author’s practice is limited to consultations on learn-
hyperactive syndrome, while they admitted that t h e
ing and behavioral disorders, and this study represents the
symptom complex of impulsivity, short attention
prevalence of hyperkinetic syndrome within a select popula-
span, and restlessness is often somewhat atypical or tion of learning-disabled children, not school children in
obscured by psychogenic or social factors [141. general. Only right-handed boys aged 5 through 11 years 3
Whether hyperactivity is organic, developmental, months were included. Score on either full-scale verbal or
or temperamental [12, 14, 151, evidence of a performance IQ had to be 90 or above. For 5- and 6-year-
physiological basis for t h e symptom complex has olds, evidence of average potential (within 1.0 SD of mean
therapeutic implications. W e n d e r [ 141 accepted as percentile for age) on the Raven Coloured Progressive
“valuable information” reports of a child’s clumsiness Matrices and o n the Peabody Picture Vocabulary Test was
or poor pencil control. Schain [ l l ] suggested that accepted in lieu of Wechsler IQ data, often unavailable for
better age norms would permit establishment of “soft such young children. Neurologicd examination had to be
free from any subtle neurological soft signs, such as reflex
signs” defined in a developmental context. Such
asymmetries. N o stipulation as to previous or subsequent
neurodevelopmental anomalies belong to a class of medication was made, but all recorded examinations of
soft signs distinguished from that of subtle or border- coordination were done when the child was not taking any
line manifestations of traditional neurological abnor- medication. If the principal complaint placed greater con-
malities (e.g., reflex asymmetries, involuntary cern on academic learning than on general conduct in home
movements, and equivocal plantar responses) [lo]. and school, the child was not included in this study.
When these traditional neurological soft signs are ab- The diagnosis of hyperactive syndrome was based on
sent, the syndrome is diagnosed as developmental ratings of the parents and teacher questionnaires designed
hyperactivity 111, 151. by Connors [lI. These questionnaires consist of descriptions
The present study was designed to determine of problem behaviors, forty-eight on the parental and
whether hyperactive children w h o have neither learn- twenty-eight o n the teacher’s list. Ten items o n each list are
ing disabilities nor subtle traditional neurological soft scored for the diagnosis of hyperactive syndrome in Con-
signs have measurable anomalies for their age ob- nors’ method [I]; we scored nine items and dropped any
child for whom the itemdifficulty in learning was checked by
servable o n a five-minute examination of coordina-
parent or teacher as “pretty much” or “very much.” If “just a
tion. little” was checked, the child was included in the study but
that one point was not added to his hyperactive syndrome
Material rating. From these nine items [ l l with a possible score range
We reviewed the charts of 332 boys between 5 and 11 years of 0 through 27, the child had to be rated at least 16 on both
old who were seen consecutively during the period June, parent and teacher questionnaire in order to be included as a
1972, through June, 1974, in the office of the senior author “hyperactive” subject. Forty-eight boys were included in the

From the Learning Disabilities Clinic, Children’s Hospital Medical Accepted for publication Aug 2 7 , 1977.
Center, Boston, MA, and the Department of Medical PsYchologY,
Address reprint requests D~~ ~ ~ ~ k ~ l ~ ~~ , ~ d~ i - ~ i
Coiumbia University College of Physicians and Surgeons, N e w
cal Center, 300 Longwood Ave, Boston, MA 021 15.
York, N Y .

0364-5 134/78/0003-0307501.25 @ 1978 by the American Neurological Association 231

study. Informed consent for testing these children was converted to standard score equivalents based on the mean
obtained from their parents following explanation of the and standard deviation of scores obtained for controls 131at
procedure involved. the corresponding age level. (For hyperactive 11- and 12-
Fifty controls from a previously reported normal popula- year-olds, the scores of normal 10-year-olds were used to
tion [3] were randomly selected from the total group of boys compute z-scores). The twelve z-scores and raw scores on
with scores of less than 10 (Teachers’ Form, Connors’ Rating overflow and dysrhythmia for each individual were entered
Sca1es). into a stepwise linear discriminant function analysis. Nine
variables were selected according to the criterion of Rao’s V
Methods for inclusion in the discriminant equation.
Scoring of Quantitative Data Results
Each of the 4 8 subjectswas examined by one ofus (M. B. D.)
N i n e discriminating variables produced a highly sig-
using the conventional neurological examination; hand,
foot, and eye preference tests; and a timed coordination nificant degree of dissimilarity between t h e hyperac-
battery [2, 31. IQ data were obtained from school records. tive subjects and t h e controls (Figure). For the discri-
Peabody Picture Vocabulary Test and Raven’s Coloured minant function yielded by these variables, Wilks’
Progressive Matrices were performed on the same day as the lambda = 0.4595 (p < 0.001), and t h e canonical
neurological examination. Motor tasks from the conven- correlation between t h e discriminant function and
tional examination of rapid alternating coordination were g r o u p membership was 0.735 (see the Table). Of t h e
timed for twenty repetitions, including tasks listed in the nine discriminating variables, overflow and heel-toe
Table. Normative data had been obtained from a middle- made t h e greatest contribution to t h e discriminant
class suburban school system drawing upon the same popu- function score.
lation as the practice of the senior author [2, 31. The computed discriminant scores for each indi-
vidual w e r e used to classify h i m according to probable
Scoring of Qualitative Data membership in the hyperactive or the normal group.
Subjects and controls received separate scores for the right-
and left-sided performances on eight different movements.
We recorded the following types of movement errors: dys-
rhythmia, synkinesis (i.e., ipsilateral overflow), mirror
movements (i.e., homologous contralateral overflow), and
total failure to perform recognizably. Overflow included
synkinetic and mirror movements which are called “as-
sociated movements” by other authors [ 7 , 1I]; dysrhyth-
mia described “lack of smooth transitions” [6] or “disorgani-
zation of sequence and slow ‘sticky’turns” [9]. Although the
test items were derived from traditional tests of rapid alter-
nating movements, the term dysrhythmia was deliberately
chosen to avoid any implication of neuroanatomical spe- 1 1.00 2.00 3m
cificity. Subjects received a score of 1 on each performance DISCRIMINANT FUNCTION SCORES
for which dysrhythmia was noted; a score of 1 was also given
for performance of any overflow movement, whether or not Distributions of standardized discriminant function scores
dysrhythmia was also present. These qualitative scores were for normal and hyperactiw children.

Coordination Characteristics in Order of Contribution t o Discriminant Function Analysis’

Variable Standardized Unstandardized’

Overflow -0.53311 -0.2991 1
Toe taps -0.42988 -0.2 0684
Heel-toe 0.47494 0.40709
Hand pats 0.18129 0.18300
Hand pats -0.20854 -0.22572
(right-left differences)
Pronation-supination -0.32298 -0.23976
(right-left differences)
Finger taps 0.30687 0.26012
Finger-to-thumb -0.22090 -0.17864
(successive)
Finger-to-thumb 0.18125 0.17426
(right-left differences)
Tonstant = 0.62797.

232 Annals of Neurology Vol 3 N o 3 March 1978

The cutoff point (-0.01493) was midway between the linear discriminant function list (see the Table). Sig-
mean discriminant scores for the normal and hyperac- nificance of persistent associated movements is in ac-
tive groups (0.7 1662 and -0.74648, respectively). cord with the reports of Touwen and Prechtl[31 and
Individuals with a discriminant score higher than of Hart and Carter [61. The development of the ability
-0.01493 were classified as probably normal and to make discrete, isolated (as opposed to massive
those scoring less, as probably hyperactive. Of the global) movements, such as the flexion of a finger,
entire sample, 88.8% was correctly classified in the requires that an individual be able “to activate the
appropriate group: 79.2% of the hyperactive group called-for flexions and to inhibit the reflexly associated
and 98.0% of the normal group. contraction of the other finger flexors” [7]. These
A second linear discriminant function analysis was associated (overflow) movements appear to be the
computed without the overflow and dysrhythmia stigmata of deficient motor inhibitiodcontrol [5],
scores. Six variables-toe taps, heel-toe, finger repeti- which has been suggested as being central to the
tion, hand pats (left and right differences), hand hyperactive syndrome [l, 4, 81.
pronation-supination (left and right differences), and
finger-to-thumb (successive differencebagah pro-
~~ ~~~~~~

Supported by the Robinson Ophthalmic and Dyslexia Research

duced a highly significant degree of dissimilarity be- Fund.
tween the two groups: Wilks’ lambda = 0.6034 (p < The authors are grateful to Megan Mery for assistance in chart
O.OOl), and the canonical correlation yielded by the review and data abstraction; to Minna Petrovics and Roben Sciacca
discriminant function = 0.630. Of the entire sample, for statistical analysis, to Marlene Duchesneau for manuscript typ-
80.6% was correctly classified in the normal or ing, and to Barbara Howard for editing.
hyperactive group.
Overflow movements differentiated hyperactive
References
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Denckla and Rudel: Hyperactivity and Coordination 233