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Pediatric Neurooncology Program, Department of Pediatric Oncology and Hematology, Charite-Universitatsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
Department of Child and Adolescent Psychiatry, Charite-Universitatsmedizin Berlin, Augustenburger Platz 1, Berlin, Germany
Department of Psychiatry, University of Leipzig, Germany
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 15 May 2008
Received in revised form 30 July 2008
Accepted 30 July 2008
Development of ne motor functions, especially drawing and handwriting, are crucial for performance in
school, autonomy in everyday life and the general human development. A variety of neurological and
psychiatric conditions in childhood and adolescence stunt the normal development of ne motor skills.
We sought to dene the normal development of the kinematic parameters of ne motor movement and
determine the inuence of gender, laterality of handedness and extracurricular training on ne motor
skills.
One hundred and eighty-seven children and adolescents (mean age: 11.6 years (S.D.: 3.58), range: 6
18 years) were included in the study. Participants performed drawing and handwriting tasks on a digitizing
graphic tablet. Movement and pressure data were transferred to a computer using a sensor-equipped pen and
post-processed using CSWIN. Movements were segmented into strokes and several kinematic parameters
were calculated. The kinematic parameters that were analyzed represented speed (frequency and stroke peak
velocity), automation (number of direction changes of velocity per stroke), variability (variation coefcient of
stroke peak velocity) and pressure.
Progression of kinematic parameters for each movement domain of the handwriting and circle
drawing tasks correlated signicantly with age (Pearsons correlation, p < 0.003). Speed, automation and
pressure increased with age, whereas variability decreased. Nonlinear regressions revealed maturation of
hand movements at a certain age. Age of completed maturation depended on the task complexity
(drawing circles vs. handwriting) and kinematic parameters. In the speed and automation domains,
handwriting movements nish maturing later than circle drawing. Male subjects drew circles at
signicantly higher speeds than female subjects. Fine motor practice and laterality of handedness did not
inuence kinematic parameters. A repeated measure ANOVA conrmed the signicant interdependency
between age and complexity level for speed and automation (p < 0.001).
The digitizing graphic tablet is an extremely valuable tool in determining the normal development of
hand movement skills of children and adolescents by measuring relevant daily tasks like handwriting and
drawing. In our study, we showed that future analyses of impaired movement in children and adolescents
need to take age and gender into consideration. Furthermore, differences were observed in the
maturation of different task complexities, the complex ne motor function reaching maturity later than
basic and repetitive movement patterns.
2008 ISDN. Published by Elsevier Ltd. All rights reserved.
Keywords:
Hand writing development
Digitizing tablet
Kinematic analysis
Maturation
Children and adolescents
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657
with the commercially available program CSWIN 1.2 (Marquardt and Mai, 1994)
and analyzed with SPSS 15.0. Non-parametric kernel estimation was used for the
calculation and smoothing of movement derivatives like velocity and acceleration
(Marquardt and Mai, 1994). Writing and drawing movements were segmented into
vertical strokes, i.e. up and downward movements. A stroke segment ended when
the velocity projection on the y-axis passed through zero. Although all strokes of the
writing tasks were included in analysis, only the rst 99 strokes of the 30 s circle
drawing task were analyzed.
Several kinematic parameters were determined for each of the tasks. We
categorized them into four movement domains of handwriting. Speed, the most
commonly described feature of hand movement in the literature, constitutes the
rst movement domain (Blank et al., 1999; Lange-Kuttner, 1998; Hamstra-Bletz
and Blote, 1993; Tucha and Lange, 2001; Schoemaker et al., 2005; Van Mier, 2006;
Mergl et al., 1999). Another important characteristic of hand movement is its degree
of automation. When movements are highly automated and smooth, they are
conducted without hesitation and display a low number of direction changes of
velocity and acceleration within a single stroke (Schoemaker et al., 2005; Mergl
et al., 1999; Tigges et al., 2000; Eichhorn et al., 1996). The next important feature of
hand movement is the variability of stroke peak velocity and stroke duration
(Phillips et al., 1999; Mergl et al., 2004a). Low variability is important for an efcient
and rhythmic pattern of movement. The fourth parameter assessed mean writing
and drawing pressure, which reects the underlying tension of the movement
(Lange-Kuttner, 1998).
Fig. 1. Distribution of age and gender. Each age group included a minimum of 30
subjects. f: female; m: male.
1.2. Assessment
Trained test supervisors interviewed all children and adolescents. We used a
questionnaire that included the Edinburgh Handedness Inventory and several
questions about gross and ne motor practice. We assessed hours of extracurricular
ne motor activity per week (e.g.: crafting, playing music, tinkering), of
extracurricular muscular energy consuming activity (e.g.: bodybuilding, gardening,
rowing), and of playing computer games. Furthermore, we assessed whether
subjects performed activities that required parallel hand movements (e.g.: playing
piano or violin, ten nger writing on a keyboard). All data on gross and ne motor
practice are based on the subjects self-assessment. Reliability and validity of our
questionnaire was not tested. Edinburgh Handedness Inventory determines a
laterality score between 100, i.e. maximal lateralized left-hander and +100, i.e.
maximal lateralized right-hander. Assessments and interviews were carried out in
quiet classrooms and lasted approximately 30 minutes. Participants were seated
comfortably in their usual school chairs with a back. Size of chairs and tables were
adjusted to the height of the subjects. The pupils were assigned several writing and
drawing tasks. The task composition was analogue to those in prior studies of adults
(Mergl et al., 1999, 2004a; Tigges et al., 2000).
Participants used a specialized pen equipped with a sensor that did not produce
an ink trace, in order to prevent visual control of the trace. The tip of the pen
consisted of a simple plastic imitation of a pencil lead without a ball. Tasks of
different demands were performed on white paper sheets that were labeled with
task graphics. A header containing brief instructions was written on the sheets.
Tasks were explained verbally, suitable to age and comprehension of the
participant. An overview of the tasks used in this study is listed in Table 1. Circle
drawing was to be carried out at maximum velocity because previous studies
showed the most reliable effects of age under this condition (Blank et al., 1999;
Carlier et al., 1993). First grade pupils (11 boys and 15 girls) did not perform the
writing task (task 2).
Task sheets were xed under the transparent overlay of a digitizing graphic
tablet (WACOM IV), which imitated the papers surface. Friction of that foil was
comparable to the friction of normal paper (WACOM Translucent Overlay).
Performance was visualized on the screen in order to administer the tasks and to
verify that they were carried out correctly. Participants were not able to see the
screen and thus had no visual feedback. Position and pressure of the pen were
detected with a sampling rate of 200 Hz and a spatial resolution of 0.05 mm.
Measurements began automatically when the participant rst touched the pen to
the digitizing tablet. All kinematic data were transferred to a PC, post-processed
(a) Speed: Frequency (F) of strokes and arithmetic mean of stroke peak velocity
(SPV).
(b) Automation: Number of changes of y-axis velocity (NCV) from acceleration to
deceleration and vice versa, i.e. number of y-axis velocity maxima and minima,
per stroke.
(c) Variability: Variation coefcient of stroke peak velocity (VARPV) and stroke
duration (VARD).
(d) Writing and drawing pressure (P).
2. Statistical analysis
2.1. Selection of kinematic parameters
CSWin provides more than 50 different variables for analyzing
various kinematic parameters. We considered a reduction of
variables for practical reasons. Therefore, the variables were fed
into a factor analysis of main components (eigenvalue > 1) that
extracted four independent components for the analysis in task 1
and ve components in tasks 2 and 3. These components
corresponded with the movement domains mentioned previously.
One representative kinematic parameter was chosen for each
component. The factor analysis indicated that NCV (automation),
SPV (speed), VARPV (variability) and P (pressure) were representative for the respective components. Frequency of strokes (F) was
used in all analyses because it was a major factor in earlier studies
and allows comparability with similar investigations. Furthermore, VARD was added in tasks 2 and 3 as the additional
component extracted for these tasks in the factor analysis.
2.2. Analysis of kinematic parameters considering different variables
2.2.1. Age
Each of the relevant kinematic parameters for a simple (circles)
and a complex (sentence) task of the dominant hand was
correlated to age (Pearsons correlation). If correlation was
signicant, regression analysis of linear, logarithmic, square and
Table 1
Overview of tasks
Task 1
Task 2
Task 3
Task
Description
Circles
Sentence
Letters a, lower case
Smooth and quick drawing of circles between two lines (16 mm apart) with the dominant hand for 30 s
Smooth cursive writing of the German sentence Der Ball rollt ins Tor. Speed is not critical (1st grade pupils were excluded)
Fluent cursive writing of letters a between two lines 10 cm long and 1.8 cm apart (ca. eight letters)
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Table 2
Kinematic parameters of speed, automation, variability and pressure in different handwriting and drawing tasks
Age groups
Circles
F
SPV
NCV
VARPV
P
Sentence
F
SPV
NCV
VARPV
VARD
P
Letters
F
SPV
NCV
VARPV
VARD
P
67 years
89 years
1011 years
1213 years
1415 years
1618 years
2.62 (0.73)
108 (30.6)
0.19 (0.14)
23.0 (6,0)
1.86 (0.91)
2.8 (0.89)
111 (36.6)
0.18 (0.16)
19.1 (4.2)
1.92 (0.78)
3.61 (0.77)
148 (55.5)
0.05 (0.06)
17.2 (3.6)
1.96 (0.76)
3.42 (0.73)
127 (52.3)
0.08 (0.12)
16.2 (5.0)
2.59 (0.85)
3.34 (0.95)
104 (51.4)
0.07 (0.12)
13.9 (4.0)
2.81 (0.69)
3.4 (0.92)
114 (56.9)
0.06 (0.09)
13.5 (2.9)
2.68 (0.76)
1.69 (0.36)
43.4 (9.6)
0.40 (0.14)
50.2 (7.6)
53.7 (9.8)
2.06 (0.73)
2.03 (0.51)
49.7 (15.9)
0.30 (0.13)
47.0 (8.3)
52.4 (12.6)
1.87 (0.83)
2.82 (0.68)
52.6 (14.6)
0.16 (0.11)
43.3 (9.0)
45.3 (15.5)
2.31 (0.78)
2.79 (0.71)
46.0 (17.8)
0.18 (0.13)
37.9 (7.7)
43.1 (13.8)
2.49 (0.64)
3.06 (0.73)
48.2 (15.3)
0.14 (0.16)
40.5 (7.2)
40.1 (14.0)
2.43 (0.75)
1.53 (0.42)
30.8 (6.8)
0.55 (0.19)
36.3 (10.0)
39.7 (10.3)
2.30 (0.86)
1.71 (0.42)
34.2 (9.1)
0.46 (0.16)
32.9 (8.6)
41.6 (11.4)
2.18 (0.87)
1.91 (0.41)
30.4 (6.7)
0.38 (0.16)
30.5 (9.5)
37.7 (16.5)
2.75 (0.86)
1.93 (0.67)
29.5 (11.5)
0.40 (0.20)
25.6 (9.7)
33.3 (12.3)
2.8 (0.79)
2.02 (0.46)
30.2 (10.7)
0.35 (0.19)
28.5 (10.3)
34.6 (13.3)
2.76 (0.83)
1.05 (0.52)
25.4 (8.6)
0.80 (0.26)
39.5 (12.0)
48.2 (11.4)
2.13 (0.72)
Values represent the means of each age group. Values in parenthesis indicate S.D. values. F: frequency of strokes (Hz); SPV: arithmetic mean of stroke peak velocity (m/s);
NCV: number of direction changes of velocity per stroke (common logarithm); VARPV: variation coefcient of stroke peak velocity (%); VARD: variation coefcient of stroke
duration (%); P: pressure (N).
659
Fig. 2. Non-linear regression analysis of age for tasks 1 and 2. Non-linear regression curves show maturation of kinematic parameters. Age of completed maturation
corresponds to the curves plateaux. F: frequency of strokes; NCV: number of direction changes of velocity per stroke (common logarithm); VARPV: variation coefcient of
stroke peak velocity.
years of age in task 2 (r2 = 0.23, Fig. 2). VARD also correlated highly
signicantly with age (Pearsons correlation: p < 0.001) in both
tasks (correlation coefcients of VARD: 0.28 in task 1 and 0.38
in task 2). The regression analysis curve reached a plateau at an age
of 15 years in task 1 (r2 = 0.1, Fig. 2) yet not until 18 years in task 2
(r2 = 1.5, Fig. 2).
3.1.1.4. Pressure. Pressure correlated signicantly with age (Pearsons correlation: p < 0.003) in both tasks (correlation coefcients
of P: 0.4 in task 1, 0.23 in task 2). Regression analysis for P produced
a curve that plateaued at an age of 15 years in both tasks 1 and 2
(r2 = 0.19 and 0.08, respectively, Fig. 2).
3.1.2. Inuence of gender, ne motor practice and laterality level
We modeled the gender differences in the kinematic parameters using univariate general linear modeling with age as a
covariate because it strongly inuences kinematics of drawing
and handwriting as shown in the previous section. Age distribution of male and female subjects was not identical. Hence, a
corrected comparison of both gender groups may eliminate the
confounding effect of age. Four kinematic parameters were tested
(NCV, F, VARPV and P). Speed (F) in drawing circles was the only
parameter that showed a signicant gender difference (p = 0.009)
when analyzed for gender after the Bonferroni correction of the
probability level (p < 0.0125). The estimated mean was 3.39 Hz
(95% condence interval: 3.21; 3.57) in the male group and
3.06 Hz (95% CI: 2.89; 3.23) in the female group. There was a
statistical trend for females showing lower NCV values in writing a
sentence (p = 0.053). For this kinematic parameter, the estimated
mean for the male group was 0.27 (95% CI: 0.24; 0.3) and 0.23 (95%
CI: 0.2; 0.26) for the female group. VARPV in drawing circles
showed a tendency towards lower values in females (p = 0.04), but
failed to reach signicance upon correction. The modeled mean
was 17.77% (95% CI: 16.84; 18.7) in the male group and 16.47%
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Fig. 3. Prole plots of repeated measures ANOVA. The continuous line represents task 1 (drawing circles), dotted line task 2 (writing a sentence), and dashed line task 3
(writing letters). Maturation of these tasks was signicantly different for speed and automation (signicant within subject effect of task-complexity on age). F: frequency of
strokes; NCV: number of direction changes of velocity per stroke (common logarithm).
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Table 3
Age of completed maturation of a simple and a complex task
Speed (F)
Automation (NCV)
Variability (VARPV)
Pressure (P)
Circles (y)
Sentence (y)
11
13
15
17
16
16
15
Slopes of non-linear regressions approximating zero indicate completed maturation. Age, at this point, is displayed for each of the four movement domains and two
tasks. Slope of VARPV in Circles did not approximate zero in the measured eld. F:
frequency of strokes; NCV: number of direction changes of velocity per stroke;
VARPV: variation coefcient of stroke peak velocity; y: years.
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4.4. Limitations
This study concentrated on the investigation of simple drawing
and writing performance. It did not collect data about general
school performance or academic achievements. Hence, the
predictive value of the kinematic analysis for general intellectual
abilities was not determined.
In the short interview before the test, we only asked for history
of neurological diseases and medication. No specic neurological
and neuropsychological assessments were conducted. The absence
of neurological anomalies and the normal distribution of
neuropsychological features can only be assumed but was not
veried.
Only the movement output of central nervous motor network
processes was investigated. Conclusions about underlying central
nervous mechanisms can only be reached indirectly. Studies using
functional MRI or MR Diffusion Tensor Imaging are required in
order to gain direct information about the development of cortical
areas and myelination of cortical and corticospinal tracts involved
in handwriting.
The sample size of 187 participants was sufcient to detect
crucial developmental features of hand movements. Nevertheless,
the number of 15 boys and 15 girls in two years interval is still too
small to establish robust percentile curves.
5. Conclusion
This study provides normative data about important movement
properties of handwriting and drawing movements in children and
adolescents. Knowledge of the distribution of kinematic parameters in healthy subjects is crucial for the understanding and
evaluation of peers, who suffer from motor impairment. Our
ndings may optimize and objectify the diagnostic methods,
enabling better assessment of deciencies in motor function of
pediatric patient groups.
Movement parameters of handwriting and drawing strongly
correlate with age in children and mature towards adolescence,
remaining rather constant throughout adulthood (Mergl et al.,
1999). Therefore, the examination of these movements in children
and adolescents must be age-specic. The maturation of such
movements also depends on the complexity of the task. Development of a simple movement, like drawing a circle, concludes
earlier than the development of the special skill handwriting. The
motor learning process of handwriting maturation seems to be not
yet completed in primary school. Movement properties are
inuenced by age and gender, whereas an inuence of extracurricular ne motor practice and extent of laterality was not
found.
We conclude that the analysis of data provided by a digitizing
graphic tablet is a valuable approach to detecting deviations of
normal hand movement skills at the level of a handicap, such as
handwriting impairment, which is relevant to everyday life.
Further studies that examine the impact of impaired kinematic
parameters of ne motor functions on academic achievement are
warranted. This next step would be to demonstrate the digitizing
graphic tablets capability to identify those pupils who need special
training in ne motor movements.
Acknowledgements
We acknowledge the support of Kind-Philipp-Stiftung by
providing a doctoral thesis scholarship to S.M. Rueckriegel. We are
highly indebted to the principals Mr. Schuknecht, Mr. Panteleit and
Mr. Balan and their students for their support of the study. We
gratefully acknowledge the help of the senate of Berlin. We are
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