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Bender Visual-Motor Gestalt Test in Adolescents:

Relationship between Visual-Motor Development and
the Tanner Stages

Article  in  Perceptual and Motor Skills · August 2013

DOI: 10.2466/10.22.25.PMS.117x10z1 · Source: PubMed

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 Perceptual & Motor Skills: Physical Development & Measurement
2013, 117, 1, 1-19. © Perceptual & Motor Skills 2013

BENDER VISUAL-MOTOR GESTALT TEST IN ADOLESCENTS:

RELATIONSHIP BETWEEN VISUAL-MOTOR DEVELOPMENT
AND THE TANNER STAGES1

LÍVIA DE FREITAS KEPPEKE, ISA DE PÁDUA CINTRA, AND

TERESA HELENA SCHOEN

Federal University of São Paulo

Summary.—Visual-motor skill is fundamental to human development and

is an important component of psychological evaluations. The goal of the present
study was to determine whether there is a correlation between visual-motor devel-
opment, as measured by the Bender Visual-Motor Gestalt Test (Bender test), and
sexual maturity in adolescents, based on the Tanner Stages in Adolescents. 134 ado-
lescents from 10 to 15 years of age participated in the study. The Bender test and
the Raven's Progressive Matrices Test were employed. The measures were adminis-
tered individually and information on sexual maturity and the presence of develop-
mental disorders was collected from medical charts. The results of the Bender test
were not affected by gender, age, schooling, or changes stemming from puberty, but
were significantly affected by having repeated a school year and by developmental
disorders. An association was found with Raven's scores. The Bender test proved
sensitive to developmental disorders in adolescence. No association was found
between visual-motor development and sexual maturity in adolescents.

Visual-motor skill is fundamental to human development and allows

for adequate interaction with one's environment. It involves the ability to
coordinate vision with body movements, especially in the hands, and it
is a central component of psychological evaluation (Sanghavi & Kelkar,
2005). According to Picq and Vayer (1988), visual-motor skill is the result
of a progressive, organic maturation process, as well as the fruit of per-
sonal experience, including formal education.
Visual-motor skill is fundamental to the scholastic learning process
because its proper development is essential to good performance in aca-
demic activities (Sisto, Santos, & Noronha, 2004). In addition to recognizing,
discerning, and interpreting stimuli (perception of patterns, spatial relations,
and the organization of figures), this ability demands the work of muscle
groups responsible for the execution of complex movements (Araujo, Pra-
cownik, & Soares, 1999) such as reading and writing, and allows a child to
copy words from a chalkboard, for example. Learning to read and write
depends on the development and interrelationship of a broad range of cog-
nitive and psychomotor skills (Koppitz, 1968; Suehiro & Santos, 2005).

1
Address correspondence to Teresa Helena Schoen, Centro de Atendimento e Apoio ao Ado-
lescente, Universidade Federal de São Paulo, Rua Botucatu, 715, Vila Clementino, São Paulo,
Brasil CEP 04023-062 or e-mail (rpetrass@uol.com.br).

DOI 10.2466/10.22.25.PMS.117x10z1 ISSN 0031-5125

2 L. DE F. KEPPEKE, ET AL.

The Bender Visual-Motor Gestalt Test is an internationally applied

standard for measuring visual-motor development, and employs different
correction systems (Archer & Newsom, 2000; Noronha, Beraldo, & Oliveira,
2003; Suehiro & Santos, 2005; Decker, 2008). Among a variety of applica-
tions and interpretation methods, the Bender test is used as an instrument
for the verification of preceptor-motor maturation in children (Lauretta
Bender System), as a projective instrument (Clawson and Hutt System), to
assess maturity in learning and to diagnose brain injury (Koppitz System),
and to aid in differential diagnosis (Pascal and Suttel System), in addition
to other uses (Nunes, Ferreira, & Lopes, 2007). The Bender Test was origi-
nally designed by Lauretta Bender in 1938 to furnish a visual-motor matu-
rity index (Silva & Nunes, 2007). While administering the test to individuals
of different ages with and without psychiatric or developmental conditions,
Bender noticed that the protocols for the testing of normal individuals only
ceased presenting errors after the onset of early adolescence. She therefore
deduced that visual-motor maturity must be reached by about 11 years of
age (Bender, 1938, 1985). Until the age of 11 years, the Bender test is used to
assess perceptual-motor development. After this age, other factors seem to
have more influence on the score. In childhood and during later stages of
maturity, it is used to assess manifestations of pathology or physical, psy-
chological, or social risk (Cousino & Wilder, 1978; Shapiro & Simpson, 1995;
Romi & Marom, 2005; Murayama, Iseki, Yamamoto, Kimura, Eto, & Arai,
2007; Santos & Jorge, 2007; Sheikhi, 2007; Pacanaro, Santos, & Suehiro, 2008;
Vendemiatto, Santos, & Suehiro, 2008; Silva, Feil, Souza, & Paniagua, 2009;
Böhm, Lundequist, & Smedler, 2010; Sardinha, 2011).
Reports on the research of Ferreira, Feil, and Nunes (2009) indicate
that the Bender test is a sensitive instrument for aiding in the identifica-
tion of neurologic disorders in maturation level. High functioning chil-
dren or adolescents with Autism Spectrum Disorder (Volker, Lopata,
Vujnovic, Smerbeck, Toomey, Rodgers, et al., 2010), Attention Deficit
Hyperactivity Disorder (Allen & Decker, 2008), hearing impairment
(Gemignani & Chiari, 2000), dyslexia (Santos & Jorge, 2007) or con-
sequences of prematurity (Chaudhari, Otiv, Chitale, Pandit, & Hoge,
2004) had worse scores on the Bender test than control groups. Many
studies have employed the Bender test in adults or adolescents, usually
when neurological or psychiatric difficulties have been identified (Di
Blasi, Elia, Buono, Ramakers, & Di Nuovo, 2007; Santos & Jorge, 2007;
Sheikhi, 2007; Pacanaro, et al., 2008; Vendemiatto, et al., 2008; Hamid &
Ghafari, 2009; Sardinha, 2011).
According to Bartholomeu and Sisto (2008), visual-motor maturity is,
in some way, associated with intelligence. Studies report significant corre-
lations between visual-motor maturity (for which the Bender test is usually
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 3

the measure employed) and intelligence (determined by different measures,

range r = −.37 to −.57: Cousino & Wilder, 1978; Shapiro & Simpson, 1995;
Bolen, 2003; Ghassemzadeh, Tahvildar, Rezai, & Danekar, 2004; Romi &
Marom, 2005; Rueda, Bartholomeu, & Sisto, 2006; Di Blasi, et al., 2007; Bar-
tholomeu & Sisto, 2008; Pacanaro, et al., 2008; Sisto, Bartholomeu, Rueda,
Santos, & Noronha, 2008; Böhm, et al., 2010).
Visual-motor ability is related to readiness for learning, not only in
childhood. Suehiro and Santos (2005) administered the Bender test to chil-
dren and adolescents divided into groups based on learning difficulty,
rated as accentuated, moderate, mild, and apparent absence of difficulty.
The results revealed that poorer test performance was associated with
greater learning difficulties. Romi and Marom (2005) found an association
between the results of the Bender test and the school dropout rate of ado-
lescents with delinquent behavior. Silva, et al. (2009) found an association
between poor performance on the Bender test and academic problems in
children and adolescents who were 5 to 12 years of age. An association
between the Bender test and academic performance, especially in math-
ematics and/or reading and writing, is commonly reported (Cousino &
Wilder, 1978; Nielson & Sapp, 1991; Cunha & Machado, 2006).
The Bender test evaluates by scoring the presence of errors, so lower
scores indicate greater visual-motor skill. Noronha, Santos, and Sisto
(2007) and Rajabi (2009) observed a decrease in scores with increasing age.
The studies of Bolen (2003), Fernández and Tuset (2007), Ferreira, et al.
(2009), Özer (2011), and Pinto and Noronha (2010) also obtained the same
results. For this reason it may be that the majority of studies employing
the Bender test have been restricted to individuals in childhood and early
adolescence (10, 11, and 12 years of age), as observed by Lauretta Bender
(1938). However, Decker (2008) suggests that rapid visual-motor matura-
tion takes place in middle adolescence, followed by a slow decline during
adulthood and a sharp decline in subsequent phases of life. Shapiro and
Simpson (1995) and Bolen (2003) suggest that there is a continuation of
visual-motor development beyond the age of 11 years.
As with the acquisition of cognitive and motor skills throughout
childhood, sexual and anthropometric changes also occur during puberty.
The authors hypothesized that the process of growth and development
in adolescence may influence visual-motor skills. Puberty marks the
onset of adolescence, which, according to the World Health Organization
(WHO), extends from the age of 10 to 19 years. Puberty involves the devel-
opment of secondary sexual characteristics, including the appearance of
pubic hair, breast development, enlargement of the genitals, and a growth
spurt (WHO, 2008). In adolescents, the analysis of sexual maturity is of
the utmost importance to specialists for the establishment of correlations
4 L. DE F. KEPPEKE, ET AL.

with other physical phenomena and the formulation of recommendations.

Adolescents of the same chronological age may be classified as being in
different stages. Thus, age is no longer a realistic parameter for bio-psy-
chosocial characterization (Chipkevitch, 2001; Lourenço & Queiroz, 2010).
With the exception of the fetal period, there is no other stage in human
development in which height, weight, growth, and changes in body com-
position are as intense and as fast as in puberty (Chipkevitch, 2001). A
boy grows an average of 10.3 cm per year and a girl, 9 cm. The adolescent
growth spurt also modifies body proportions that were present prior to
sexual maturity. It does not occur uniformly, and it starts with the mem-
bers (the hands and feet initially, followed by the legs and upper limbs).
By the end of the growth spurt, the adolescent's body is disproportion-
ate compared to other stages of the life cycle. The pace at which the body
changes shape is more rapid than the brain's ability to map and represent
it, resulting in motor incoordination (Colli, Coates, & Guimarães, 2003).
After the growth of the trunk, the body shape returns to being propor-
tional and harmonious. The maturation process takes place over a period
of about 4 years for both genders and begins about 3 years earlier in girls
(Papalia, Olds, & Feldman, 2001; Saito, Silva, & Leal, 2008).
The growth spurt is characterized by different periods of sexual mat-
uration among adolescent females and males (Colli, et al., 2003; Lourenço
& Queiroz, 2010). The developmental sequence of secondary sexual char-
acteristics was systematized by the English physician J. M. Tanner in 1962.
Tanner described stages of sexual maturation that are classified by inspec-
tion during physical examination, which range from stage 1 (child) to
stage 5 (adult), considering breast development (M) and pubic hair (P) for
females and the development of the external genitalia (G) and pubic hair
(P) for males (Lourenço & Queiroz, 2010).
In females, the beginning of the growth spurt occurs early in puberty
(M2), reaches a maximum speed of growth in M3, and slows down in M4,
at which time menarche usually occurs. In males, the onset of puberty (G2)
is characterized by a stable or pre-pubertal growth-spurt rate. The growth
spurt usually accelerates in stage G3, and peaks in G4, after which it begins
to slow down (Colli, et al., 2003; Saito, et al., 2008). As previously cited, the
growth spurt affects nearly all dimensions of the skeletal and muscular sy
stems, and the eyes also grow more quickly (Papalia, et al., 2001). Accordingly
to Braun, Freidlin, Sperduto, Milton, and Strahlman (1996), there is a more
rapid progression of myopia in puberty, which is greater in girls between 8
and 10 years of age (at the onset of puberty in females).
Reports suggest that pubertal development interferes with some cog-
nitive functions. Kolb and Whishaw (2002) and Machado, Bastos, Silva,
Andrade, Silva, Furtado, et al. (2005) suggest that cognitive performance
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 5

depends on the age at which sexual hormones begin to affect the brain, as
girls who have their menarche at an early age perform better on verbal tasks
than those who have their menarche later. However, members of the latter
group have better spatial skills. Physical changes due to puberty may inter-
fere with the visual-motor ability of adolescents, because puberty is marked
by nonlinear skeletal growth (which also requires an acceleration and a
deceleration period) and can result in a disproportionate body (Colli, et al.,
2003). It also seems that adolescents lose some ability to coordinate vision
with their body movements (Kolb & Whishaw, 2002; Colli, et al., 2003).
Because of the evidence of the effects of puberty (Colli, et al., 2003), the
resulting possible changes in some cognitive functions (Kolb & Whishaw,
2002; Machado, et al., 2005), and the implications of visual-motor matura-
tion after childhood (Shapiro & Simpson, 1995; Bolen, 2003; Decker, 2008),
the goal was to assess whether changes in visual-motor skills take place
precisely at the time of puberty, this being the time that Bender (1938,
1985) considered visual-motor maturation to be fully developed.
Hypotheses. Visual-motor development, as measured by the
Bender test, will be correlated with sexual maturity in ado-
lescents (small effect size), based on the Tanner Stages, by
using the methodologies of (a) testing associations between
the number of errors committed on the Bender test and demo-
graphic variables (gender, age, and schooling); (b) comparing
the results of the Bender test with the results of Raven's Pro-
gressive Matrices Test; (c) testing the association between the
results of the Bender test and the Tanner maturity stages; and
(d) identifying neurological difficulties associated with matu-
rity that may affect Bender test results.
METHOD
The present descriptive, cross-sectional study received approval from
the Human Research Ethics Committee of the Federal University of Sao
Paulo (Brazil) under process number 842/10.
Participants
Male and female adolescents (N = 134), 10 to 15 years of age (early ado-
lescence: 10 to 12 years; middle adolescence: 13 to 15 years), participated in
the study. They were recruited among patients who had a medical appoint-
ment in the Adolescent Sector of the Department of Pediatrics at the Federal
University of Sao Paulo (Brazil) on the day of the administration of measures.
Measures
Bender Visual-Motor Gestalt Test (Bender test).—This test consists of pre-
senting nine geometric figures printed on cards measuring 10 cm ⫻ 15 cm
6 L. DE F. KEPPEKE, ET AL.

that are to be copied with a B2 pencil onto a sheet of A4 paper without the
assistance of any type of mechanical device. The test lasts 7 to 10 minutes.
Scores are based on the number of errors committed, so lower scores denote
better visual-motor coordination. The test was corrected according to the
instructions proposed by Koppitz (1989), with a possible score of 0 to 30
errors. A standardization study of the Koppitz System involved 1,104 chil-
dren of both sexes, aged 5 years zero months to 10 years 11 months, and
the nine figures were applied individually. All children were from public
schools, from Kindergarten to Grade 5. Among the participants were chil-
dren with emotional difficulties, learning disabilities, brain damage, and
mental retardation. To evaluate reliability, the method of test-retest at inter-
vals of 4 months was used, and the results of the Kendall Degrees correla-
tion coefficients were between .55 and .66, which was statistically significant
(p < .001). Validation was performed by comparing each item with perfor-
mance in the 1st and 2nd degrees as measured by the Metropolitan Readi-
ness Test. One hundred sixty-five students participated; 99 were from the
first degree (59 were above average and 40 were below average) and 66
were from the second degree (45 were above average and 21 were below
average). The chi-square tests were statistically significant (p < .001) (Kop-
pitz, 1989). The results indicate adequacy of the test for children ages 6 to
10 years.
Raven's Progressive Matrices Test.—This is a non-verbal intelligence
test that assesses the g factor and is designed for individuals aged 13 years
and older. The test is made up of five sets (A, B, C, D, and E) arranged in
increasing order of difficulty, with a total of 60 items. The individual is
instructed to complete the part of the drawing that is missing by choos-
ing from among the items at the bottom of the page. A point is awarded
for each correct response. The total score is a simple sum of the scores on
each problem and ranges from 0 to 60 points. In the present study, because
some of the participants were less than 13 years of age, the results were
expressed as (a) an unadjusted result, and (b) an age-adjusted result. The
test-retest reliability of this instrument ranges from .83 to .93, depending
on age. The correlation with the Terman-Merril scale was .86. Raven (2000)
established a saturation of .82 on factor g.
Demographic chart.—Data on variables affecting visual development
were collected from the medical charts of the participants according to
the literature, as follows: (a) Tanner stage; (b) developmental conditions
(mental retardation, dyslexia, attention deficit disorder and hyperactiv-
ity, global learning disability, global developmental disability, epilepsy,
Kozlowski syndrome, arthrogryposis multiplex congenita, growth hor-
mone deficiency, and myelomeningocele); (c) age; (d) gender; and (e)
schooling, including having repeated a school year. Determination of sex-
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 7

ual maturation stage was routine for medical appointments at the clinic.
The childhood stages of development are G1 (gonads), M1 (mammary
glands), and P1 (pubic hair). Girls were considered to be in the growth
spurt phase when they exhibited the stages of P2 to P4 and M2 to M4 (the
emergence of long, downy hair to adult-type hair that has not yet reached
the inner face of the thigh, and an increase in areola diameter under the
formation of the second mound above the contour of the breast). Boys
were considered to be in the growth spurt phase when they exhibited the
stages of P3 to P4 and G3 to G4 (emergence of long, downy hair to adult-
type hair that has not yet reached the inner face of the thigh, and an initial
increase in testicular volume and in penile diameter). Girls in P5 and M5
and boys in P5 and G5 have the sexual characteristics of adults.
Procedure
After authorization by the head of the clinic, medical appointment
hours for potential study candidates were identified. Adolescents in the
waiting room were invited to participate in the study. After an explana-
tion of the project, the adolescents and parents/guardians who agreed to
participate signed a statement of informed consent. In a separate, quiet
room, the participants individually copied the figures on the Bender test
and took Raven's Progressive Matrices. Each participant took the tests
during a single session. After the participants attended their medical
appointment and took the tests, their medical charts were analyzed and
the study's demographic charts were filled out. The data were organized
on spreadsheets and analyzed.
Analysis
The Kolmogorov-Smirnov Test was employed to assess the normal-
ity of the data. The chi-square test, analysis of variance (ANOVA), and
the Pearson's correlations were used to compare the results of the Bender
test, and the other variables analyzed (Tanner stage, age, and Raven's test
results). Alpha was set to .05. “Power and Sample Size” on Minitab V16
was used to analyze the data, and the power of the sample to detect dif-
ferences was 92.22%.
RESULTS
The majority of participants in the present study were male. The mean
age of the overall sample was 12.7 yr. (SD = 1.6). Middle school (Grades
6 to 9) was the predominant level of schooling. Most of the participants
had never repeated a school year, and a small percentage exhibited devel-
opmental disorders. The P5, G1, and M5 Tanner stages predominated.
No female participants were in stages M1 or M2 (Table 1). In the ANOVA
analyses, in which all participants were included, the degrees of freedom
8 L. DE F. KEPPEKE, ET AL.

TABLE 1
DISTRIBUTION OF SAMPLE BY GENDER, AGE, SCHOOLING, DEVELOPMENTAL DISORDER,
AND SEXUAL MATURATION STAGE

Variable n %
Gender Male 76 56.7
Female 58 43.3
Age, yr. 10 22 16.4
11 8 6.0
12 24 17.9
13 33 24.6
14 29 21.7
15 18 13.4
Schooling Elementary1 28 20.9
Middle2 93 69.4
HS3 13 9.7
Repeated school Yes 30 22.4
year No 104 77.6
Developmental Present 18 15.8
disorders Absent 96 84.2
Tanner P1 27 20.2
P2 14 10.4
P3 18 13.4
P4 30 22.4
P5 45 33.6
G1 23 30.7
G2 12 16.0
G3 19 25.3
G4 11 14.7
G5 10 13.3
M3 5 8.9
M4 21 37.5
M5 30 53.6
1st to 5th grades; 26th to 9th grades; 3high school (HS).
1

(df ) were 133; for females in their growth spurt, df = 57, and for Tanner M,
df = 55; for males in their growth spurt, for Tanner G, df = 74.
The results of the Bender test were analyzed using descriptive sta-
tistics for the treatment of the data. Table 2 displays the descriptive sta-
tistics and F ratios as well as the statistical significance for the results of
the Bender test according to gender and age. The literature on the Bender
indicates no difference between the sexes, but the number of errors that
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 9

TABLE 2
BENDER TEST SCORES ACCORDING TO GENDER AND AGE
Variable n Min Max M SD F p ES
Gender Male 76 0 12 2.59 2.87
0.69 .41 .002
Female 58 0 12 3.03 3.28
Age, yr. 10 22 0 8 2.68 2.66
11 8 0 7 3.50 2.44
12 24 0 8 2.33 2.23
1.39 .55 .014
13 33 0 9 2.03 2.35
14 29 0 12 3.90 4.21
15 18 0 12 2.78 3.42

the Bender test generates diminishes with age. In this sample, there were
no significant differences between the sexes, nor by age.
Table 3 displays the ANOVA results for the Bender scores according
to level of schooling and having or not having repeated a school year. A
higher level of education was expected to decrease the number of errors on
the Bender test; adolescents with learning disabilities, here measured by
grade repetition, would have higher scores on the Bender test. The results
did not indicate a statistically significant improvement in performance on
the Bender test with regard to schooling level. In contrast, having repeated
a school year resulted in statistically significantly worse performance in
comparison to those who did not repeat a school year.
Table 4 displays the Bender test scores in relation to developmental
disorders and sexual maturation stage. It was hypothesized that adoles-
cents with organic developmental problems would commit more errors
on the Bender test. The adolescents with developmental disorders per-
formed statistically significantly less well on the Bender test in compar-
ison to those without them. The main hypothesis of this study was that
puberty, and specifically the growth spurt, influences visual-motor abil-
ity. However, the changes stemming from puberty and related to the
growth spurt (according to Tanner's Stages), such as the development of
TABLE 3
BENDER TEST SCORES ACCORDING TO ACADEMIC LEVEL
Variable n Min Max M SD F p ES
Elementary1 28 0 12 3.4 3.5
Schooling Middle2 93 0 12 2.8 3.1 1.95 .15 .014
HS3 13 0 4 1.4 1.3
Repeated year 30 0 12 4.5 4.1
12.75 < .001* .081
Did not repeat year 104 0 12 2.3 2.5
1
1st to 5th years; 26th to 9th years; 3high school (HS). *p < .05.
10 L. DE F. KEPPEKE, ET AL.

TABLE 4
BENDER TEST SCORES ACCORDING TO DEVELOPMENTAL DISORDERS AND SEXUAL MATURATION STAGE
Variable n Min Max M SD F p ES
Developmental Present 18 0 12 5.4 4.6
disorder 17.03 <.001* .148
Absent 96 0 11 2.3 2.6
Tanner P1 27 0 9 2.9 2.8
P2 14 0 12 2.3 3.5
P3 18 0 12 4.2 3.3 1.78 .14 .023
P4 30 0 9 1.9 2.4
P5 45 0 12 2.9 3.2
G1 23 0 8 2.6 2.6
G2 12 0 8 2.3 2.7
G3 19 0 12 3.2 2.9 0.69 .60 .017
G4 11 0 9 1.6 2.8
G5 10 0 8 1.8 3.0
M3 6 0 12 5.0 5.1
M4 20 0 7 2.5 2.1 1.21 .31 .003
M5 30 0 12 3.3 3.7
Female growth Spurt 28 0 12 3.1 3.1
spurt 0.02 .89 .018
Post-spurt 30 0 12 3.3 3.7
Male growth Pre-spurt 35 0 8 2.5 2.6
spurt Spurt 30 0 12 2.6 2.9 0.32 .73 .019
Post-spurt 10 0 8 1.8 3.0
*p ≤ .05.

the gonads, breasts, and pubic hair growth, were not associated with the
mean Bender test scores. Sexual maturity did not appear to affect visual-
motor skills in the present sample.
The variables that exhibited statistically significant differences among
the participants with regard to the results of the Bender test were hav-
ing repeated a school year and having developmental disabilities. A chi-
square test was then applied to these variables, which demonstrated a
statistically significant association between these variables (X2 = 7.82,
p = .005). The proportion of participants with developmental disabilities
was greater among those having repeated a school year (40%) in compari-
son to those not having repeated a school year (14.6%).
Pearson's correlation was used to assess the relationship between the
Bender and Raven's tests (unadjusted results and results adjusted for age).
The authors had hypothesized that higher results on Raven's test would
be associated with lower results on the Bender test. Figure 1 shows that
the correlation between these measures was negative. The results of the
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 11

12
(r = –.473)* (r = –.468)*
9
Bender

20 40 60 5 10 15 20
Raven Adjusted Raven
FIG. 1. Correlation between Bender and Raven tests. Raven score and adjusted-for-age
Raven score show negative correlation with Bender score. *p < .001.

Bender test are based on the number of errors, and the Raven's test results
are based on the number of correct answers, so the inverse association is
logical. The correlation between the two tests was statistically significant
(ps < .001) for both the unadjusted Raven's test score (r = –.47) and the
Raven's test score controlled for age (r = –.47).
DISCUSSION
This study attempted to assess whether there is a correlation between
visual-motor development, as measured by the Bender test, and sexual
maturity in adolescents, based on the Tanner Stages. It also sought to
investigate other variables (gender, age, schooling, intelligence, and devel-
opmental disabilities) that may have contributed to or interfered with the
purposes of the study.
With a duration of approximately 2 to 4 years (Lourenço & Queiroz,
2010), puberty, and especially the growth spurt, manifests itself in ado-
lescents who are 10 to 15 years old. Therefore, if it is possible to detect
visual-motor changes in adolescence, this 5-year period should be suffi-
cient for the study. Since the acceleration and deceleration of musculoskel-
etal growth occurs concomitantly during sexual maturation (Lourenço &
Queiroz, 2010), the study used the Tanner stages to analyze the influence
that sex hormones and the growth spurt could have on visual-motor skills.
Visual-motor changes could occur in the Tanner stages M2, M3 (girls), G3,
and G4 (boys), when the adolescent growth spurt generally occurs (Colli,
et al., 2003; Saito, et al., 2008).
As expected, no prepubescent girls were found in the sample, as
female development occurs earlier than male development, beginning on
average at 8 or 9 years of age (Monte, Longui, & Calliari, 2001; Papalia,
et al., 2001; Lourenço & Queiroz, 2010). A large proportion of the adoles-
cents in the study were still in elementary school due to having repeated
school years, and they therefore exhibited delays in age-grade relation.
12 L. DE F. KEPPEKE, ET AL.

As in the majority of studies using the Bender test (Oliveira, 1985;

Noronha, et al., 2007; Ferreira, et al., 2009; Pinto & Noronha, 2010), in the
case of this study no significant differences were found between genders,
emphasizing that our results were similar to those of others studies with
children and teenagers (Shapiro & Simpson, 1995; Decker, 2008). In the
present study, the majority of participants that showed sexual dimor-
phism had already entered puberty.
Age was not statistically significantly associated with Bender test
scores. This is in agreement with the findings described by Lauretta Bender
(1938), who suggested that visual-motor maturity is reached at the onset of
adolescence. The majority of studies that found age differences had partici-
pants with a maximal age of 10, 11, or 12 years (Bartholomeu & Sisto, 2008;
Ferreira, et al., 2009; Pinto & Noronha, 2010). In Bolen's study (2003), visual-
motor stability was found to be present in adolescence and the participants
received low scores, although errors were still observed in copying the stim-
ulus cards. While Shapiro and Simpson (1995) and Decker (2008) reported
different findings, the present study does not corroborate Decker's observa-
tion of rapid visual-motor maturity in middle adolescence (13 to 15 years of
age). While there may be no association between age and the results of the
Bender test in adolescence, this test remains an important measure during
this phase of life due to other issues, such as schooling delays and develop-
mental disabilities, as demonstrated by Santos and Jorge (2007), Allen and
Decker (2008), Pacanaro, et al. (2008), Ferreira, et al. (2009), and Volker, et
al. (2010). These individuals typically score outside of the error range nor-
mally found in this age group, as seen in standardization studies (Bolen,
2003). The deviations in scores on the Bender test would therefore be due
to other factors, such as intelligence, neurological or psychiatric disabili-
ties, and social issues. In adolescence, the coordination of vision with body
movements, especially the hands, seems to have already reached its peak
(Sanghavi & Kelkar, 2005). We emphasize that this study included only 134
participants, all of whom attended one medical clinic, so it is important to
exercise caution in generalizing from the findings.
According to Pinto and Noronha (2010), when administered in child-
hood, the Bender test is sensitive to differences with regard to grade. In
the present study, however, despite the reduction in errors among those
with more schooling, no statistically significant differences were found
that might lead one to infer that an increase in schooling level stimulates
visual-motor development in adolescence. Repeating a grade was appar-
ently the factor associated with scoring more errors on the Bender.
In the present study, teenagers who had developmental disorders
showed significantly lower performance on the Bender test. Develop-
mental disorders among the participants were many and included mental
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 13

retardation, dyslexia, attention deficit disorder and hyperactivity, global

learning disability, global developmental disability, epilepsy, Kozlowski
syndrome, arthrogryposis multiplex congenita, growth hormone defi-
ciency, and myelomeningocele. Thus, this test, in accordance with previ-
ous studies, appears to be sensitive to neurologically-based developmental
disabilities in adolescence (Santos & Jorge, 2007; Sheikhi, 2007; Allen &
Decker, 2008; Pacanaro, et al., 2008; Ferreira, et al., 2009; Volker, et al., 2010).
A large number of errors on the Bender test may indicate a neurological
disorder. It seems that these participants also had some difficulties with
higher-level cognition related to identifying objects in the outside world.
We interpret these errors as visual perception difficulties because the par-
ticipants were satisfied with their copies, saying that they were equal to
the stimulus cards. Our sample did not involve enough participants with
each type of pathology presented to allow us to correlate specific difficul-
ties in copying the figures with specific neurological disabilities, which
was a limitation of the study.
An association was also found between developmental disabilities
and having repeated a school year. It is possible that the reason for the rep-
etitions was that the participants' developmental disorders were linked
to cognitive disabilities that impeded school learning. As reported in pre-
vious studies (Cousino & Wilder, 1978; Nielson & Sapp, 1991; Suehiro &
Santos, 2005; Cunha & Machado, 2006; Silva, et al., 2009;), an association
was found between visual-motor skills and academic success. It is there-
fore likely that visual-motor difficulties stemming from developmental
disorders hamper the learning process.
Among the participants who repeated a school year, only 13 (14.3%)
had no suspected developmental disorders. This suggests that these disor-
ders are a major cause of repeating a school year, and that they also affect
visual-motor perception. Silva, et al. (2009) also found a statistically sig-
nificant association between the results of the Bender test and learning
difficulties, demonstrating that visual-motor skills constitute a cognitive
function that is essential in mastering academic activities.
Regarding the relationship between visual-motor development and the
Tanner stages, which is the main purpose of this study, no significant asso-
ciations were found between the Bender test scores and the Tanner stages or
the growth spurt. In Tanner stages M2, M3, G3, and G4, in which the adoles-
cent growth spurt generally occurs (Colli, et al., 2003; Saito, et al., 2008) there
were no significant visual-motor changes. Although adolescents experience
significant physical changes, these phenomena do not appear to affect their
performance on the Bender test. This finding appears to contrast with sug-
gestions put forth by Kolb and Whishaw (2002) and Machado, et al. (2005)
that sexual hormones affect cognitive skills. However, one should bear
14 L. DE F. KEPPEKE, ET AL.

in mind that the present study only investigated visual-motor skills and
inferred the action of hormones through secondary sexual characteristics
and the growth spurt. Is important to emphasize the small number of par-
ticipants in this study, who were also classified into subgroups according
to the Tanner stages, generating small groups. Studies with similar popula-
tions and with a larger number of participants in each pubertal stage would
provide more reliable results, including the validation of the evidence by
others.
This study's results also disagreed with Decker (2008), who suggested
a rapid visual-motor maturation during the middle period of adolescence,
13 to 15 years old, and with Shapiro and Simpson (1995) and Bolen (2003),
who also found evidence of visual-motor development after 11 years. The
current study accords with Lauretta Bender's statement that at approxi-
mately 11 years of age, visual-motor maturity becomes fully developed
(Bender, 1938, 1985). Most studies involving adolescents seem to corrobo-
rate this finding. In the current sample, visual-motor maturation appeared
to be stabilized before sexual maturity (or at least at the beginning of
it) and before other alterations resulting from puberty, and this did not
change during the growth spurt, even during the period of the rapidly
changing relationship between the upper limbs and trunk that results in
transient motor incoordination (Papalia, et al., 2001; Colli, et al., 2003). The
coordination of vision with fine motor movement that is required in the
transcription of the figures seems not have been affected by the rapid, dis-
proportionate growth that occurs during the spurt.
As reported in previous studies (Rueda, et al., 2006; Bartholomeu &
Sisto, 2008), Bender scores were correlated with Raven's test. Although
the two tests evaluate different constructs, there is a relationship between
the general factor of intelligence and visual-motor organization in ado-
lescents. Shapiro and Simpson (1995) and Di Blasi, et al. (2007) found the
same association in adolescents, indicating that it is not restricted to child-
hood, although the Bender test is standardized in most countries for this
period of development. Therefore, the ability to perform complex men-
tal operations such as logical and abstract reasoning is affected by visual-
motor development, and it is possible to verify this association using the
Bender test during adolescence, also. The results of this study suggest that
the Bender test, when corrected with the Koppitz system, contains visual
and spatial components related to those found in Raven's test. The same
visual-motor skills are likely required for both tests. It is possible that spa-
tial abilities and cognitive performance may have a similar basis in infor-
mation processing (Di Blasi, et al., 2007).
It is notable that previous studies finding statistically significant
correlations between visual-motor maturity and intelligence reported
 VISUAL-MOTOR SKILLS IN ADOLESCENTS 15

magnitudes of correlation similar to the present study (r = −.47). Bar-

tholomeu and Sisto (2008) found a correlation of −.56, Bolen (2003) of −.48,
Di Blasi, et al. (2007) of −.37, Pacanaro, et al. (2008) of −.57, and Sisto, et al.
(2008) of −.55. The difference between these values is probably due to differ-
ent types of samples and intelligence tests present in each article. Di Blasi,
et al. (2007), for example, used the WISC–R test, and Pacanaro, et al. (2008)
used the Nonverbal Intelligence Test (TONI 3–A Form) in people with
Down Syndrome from childhood to adulthood. Even so, the correlations
are similar in these reports.
It is difficult to compare mean scores of the present study with those
reported in previous ones, as there is more than one correction system
(Nunes, et al., 2007): the Koppitz (1989) system that was used in the pres-
ent study allows for a maximum of 30 errors; the Gradual Scoring Sys-
tem (Sisto, Noronha, & Santos, 2005) has a maximum of 21 points; the
Lacks system (Lacks, 1999) has a maximum of 12 points; there is also the
Clawson system (Clawson, 1992), and so forth. Nonetheless, it appears that
the participants in the present study had lower scores (M = 2.78, range =
0 to 12 errors) than those reported by Vendemiatto, et al. (2008) in their study
of adolescents in situations of risk (M = 7.12 points; range = 3 to 14 errors). Par-
ticipants in the study of Joesting (1977), who were students 6 to 16 years old
with learning difficulties, had an average error rate, according to the Koppitz
system, of 5.24. The study conducted by Bolen (2003), also using the Koppitz
system, found in adolescents a stable rate of 3 to 5 errors for each age group.
In the present study, performance on the Bender test was associated
with having repeated a school year, developmental disorders, and Raven's
scores. The majority of adolescents with suspected developmental disabil-
ities had repeated a school year. These pathologies seem to have a nega-
tive effect on the central nervous system, which results in worse scores
on the Bender test and in failure at school. This finding underscores the
importance of addressing early development when taking the patient his-
tories of adolescents. A detailed history is fundamental in cases involving
learning difficulties, which may be related to neurological and matura-
tional disorders. This study was intended to investigate only variables
that could, according to the literature, influence Bender results. Further
studies involving a larger and more distinct sample, specifically in clinics
that treat developmental pathologies, would be interesting in order verify
possible correlations between different types of neurological damage and
specific difficulties in copying the figures in the Bender test.
In this study, there was no change in visual-motor skills related to
pubertal changes in the participants during adolescence, demonstrating
that visual-motor maturity, at least in this sample of 134 Brazilian ado-
lescents, appears to be stabilized before puberty, thereby ruling out the
16 L. DE F. KEPPEKE, ET AL.

hypothesis of this study. However, there were adolescents who had errors
in copying stimulus cards. Although the Bender test was designed for
children up to 11 years of age, it proved sensitive to developmental dis-
abilities in both early (10 to 12 years of age) and middle (13 to 15 years of
age) adolescence. Because developmental disturbances seem to affect per-
formance on the Bender test among adolescents and because a correlation
between intelligence and visual-motor skills was observed in adolescence,
further studies with a larger sample are needed to verify the possibility
using this instrument in age groups of participants who are older than
those used in the current, standardized testing regime, including sample
populations of individuals with different types of pathologies.

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Accepted June 12, 2013.

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