Occupational Therapy International, 2, 229-240, 1995 © Whun Publishers Ltd

Motor skills in Australian children

with Attention Deficit
Hyperactivity Disorder

SHARON DOYLE Department of Occupational Therapy, Westmead

Hospital, Westmead NSW, Australia
MARGARET WALLEN Department of Occupational Therapy, Westmead
Hospital, Westmead NSW, Australia
STEPHANIE WHITMONT Department of Psychology, University of
Sydney, Australia

ABSTRACT The motor skills of 38 children with Attention Deficit Hyperactivity

Disorder (ADHD) were assessed. The majority of children had gross and fine
motor skills within the normal range, with age appropriate coordination. Gross
motor skills were a relative strength compared with fine motor skills. Parents' rat-
ings of children's motor skills were generally lower than performance as indicated
by standardised assessment, h is proposed that attention and concentration deficits
account for the perception that children with ADHD have impaired motor skills as
indicated by the lower ratings of parents in this domain, and for the fact that gross
motor skills were stronger than fine motor skills, i.e. that fine motor skills require
greater application to task and therefore may be more susceptible to concentration
difficulties. Intervention should be aimed at assisting children to develop strategies
to promote attention within the various environments where they are required to
participate.

Key words: attention deficit, motor skills, pediatrics.

INTRODUCTION
Attention Deficit Hyperactivity Disorder (ADHD) is a psychiatric disorder
of childhood, characterised by inattentiveness, impulsivity and motor overac-
tivity which exceeds developmental expectations (American Psychiatric
Association, 1994; Berry, Shaywitz & Shaywitz, 1985; Cantwell & Baker,
1991; Hesterly, 1986). ADHD follows a chronic course, affects between 3%
 Doyle Wallen and Whitmont

and 5% of children, and underlies significantly impaired occupational perfor­

mance in home, school and social settings (Barkley, 1990). The occupational
therapists' role with children with ADHD involves determining, in collabo­
ration with the child, family and school, how well a child is participating in
his/her necessary occupational roles (Clark, Mailloux & Parham, 1989).
Intervention may include assisting children to organise their own behaviour
or develop appropriate social skills. Occupational therapists are frequently
involved in the management of these children, where motor signs are mani­
fest and interfering with children's abilities to participate in their occupa­
tional roles.
Despite the reputation of children with ADHD for general clumsiness,
the prevalence and nature of motor involvement in this disorder have not
been systematically investigated. Clinically, their motor behaviour is
described as erratic and impulsive, at times without goal direction. A few
may show mild, non-specific neurological deficits like choreoathetoid
movements, tremor, motor overflow, neuromuscular instability, or poor
visuo-motor coordination (Barkley, 1990; Chawla, Sahasi, Sundaram &
Mehta, 1982). Slightly over half of samples of children with ADHD are
expected to manifest poor motor coordination, particularly marked on
tasks demanding fine motor skills (McMahon & Greenberg, 1977; Stewart,
Pitts, Craig & Dieruf, 1966; Szatmari, Offord &. Boyle, 1989). Poor hand­
writing skills implicating fine motor problems have been noted widely, but
not assessed with standardised measures (Gadow, 1983; Lerer, Lerer & Art­
ner, 1977; Serfontein, 1991). The evidence is mixed regarding delayed
motor milestones, with some studies reporting a risk for delay (Hartsough
& Lambert, 1985), while others fail to document motor delays (see
/Berkley, 1990).
The role of medication and its influence on the motor skills of children
with ADHD has been investigated by several groups (Gualtieri & Evans,
1988; Lerer et al., 1977; Knights & Hinton, 1969). Handwriting appears to
be the motor domain most improved by medication (Gadow, 1983; Hesterly,
1986; Serfontein, 1991)· However, it is unclear whether the motor aspects
'of handwriting are affected directly by medication, or influenced indirectly
through amelioration of ADHD indicators such as attention and impulsivi-
ty. Several authors have suggested that improved motor coordination is the
result of medication-enhanced ability to pay attention, rather than
enhanced motor speed or motor control per se (Gadow, 1983; Gordan &
Kantor, 1979; Knights & Hinton, 1969; Lerer & Lerer, 1976; Lerer et al.,
1977).
The present study investigates the prevalence and nature of motor difficul­
ties in ADHD using standardised measures in a primary school aged sample of
Australian children. Further it seeks to clarify the relationship between
parental perceptions of clumsiness and the performance of their child with
ADHD on standardised measures of motor skills.
 Motor skills in children with attention deficit hyperactivity disorder

METHOD

Subjects
All children attending the outpatient Attention Deficit Disorder (ADD)
Clinic at Westmead Hospital in Sydney (Australia) during 1992 and 1993
participated in the study. Children with ADHD were referred to the clinic
and occupational therapy assessment of motor skills was a routine part of the
multidisciplinary team involvement. The children included 33 boys (87%)
and five girls in the age range 7-12 years. Mean age was 9 years 7 months
(S.D. 1 year 2 months). All children fulfilled the DSM-IIIR (American Psy­
chiatric Association, 1987) criteria for ADHD when assessed by clinic staff
(pediatrician, child psychiatrist, clinical psychologist). This diagnosis was sup­
ported by a parent or teacher behaviour report in the clinical or borderline
range, using the Child Behavior Checklist (Achenbach & Edelbrock, 1983,
1986) and The Conners' Rating Scales (Goyette, Conners & Ulrich, 1978).
Had these children been screened using the more recent DSM-IV (1994) edi­
tion, all would fulfil criteria for the combined type of ADHD: that is, they
showed behaviours which reflect problems with sustained attention, as well as
problems with activity level and impulsive responding. The majority of chil­
dren showed intellectual ability in the average range on either WISC-R,
WISC-III (Wechsler, 1974, 1991), or Stanford-Binet IV (Thorndike, Hagen
& Sattler, 1986). Only one child showed a Full Scale IQ below 80 (see Table
1). By contrast, nearly half the sample had learning problems, indicated by
one or more achievement scores in the boVderline range or below on the Wide
Range Achievement Test - Revised (a measure of spelling, reading and arith­
metic) (Jastak & Wilkinson, 1984).

TABLE 1: Intellectual ability in participant children

Mean* Standard Deviation

Total sample 103.11 12.04

Usually medicated 102.78 9.59
Usually not medicated 103.42 14.24

Category Percentage Number**

(Range) of children of children

Borderline (70-79) 3 1
Low average (80-89) 14 5
Average (90-109) 51 19
High average (110-119) 27 10
Superior (120-129) 5 2

* WISC-R, WISC-III, or Stanford-Binet IV (1 case)

** IQ estimate not available for one of 38 children.
Doyle Wallen and Whitmont

Table 2 shows the proportion of children in various categories for lowest

Wide Range Achievement Test - Revised subtest scaled score. Fifty percent of
the sample were taking stimulant medication; 82% were right handed. Five
children had previously received occupational therapy input for motor diffi­
culties.
TABLE 2: Wide Range Achievement Test - Revised (WRAT-R): Mean for the lowest of
three subtest scaled scores.

Mean* Standard Deviation

80.95 12.75

Category Percentage
(Range) of children

Below borderline (0-69) 16

Borderline (70-79) 32
Low average (80-89) 24
Average (90-109) 27
High average (110-119) 0
Superior (120-129) 0

*WRAT-R standardisation mean == 100, S.D = 15. Subtests: oral reading, written spelling,
and written arithmetic.

Measures and procedures

Children were assessed in the Occupational Therapy Department prior to
their presentation in the ADD Clinic where further multidisciplinary
assessment and treatment occurred. Of those children usually medicated,
half were removed from medication for at least 15 hours prior to assess­
ment. The remainder were assessed on their usual medication regime. This
inconsistency was due to changing ADD Clinic policy over the two year
study period. Various analyses of groups of children on and off medication
for the assessment was carried out to determine how this may have biased
results.
The following measures were used:

• Parents' motor skill rating. Each parent was asked to rate their child for
gross and fine motor skills (five point scale: well coordinated to very
uncoordinated), and for handwriting (four point scale: above average to
very poor).
• Bruininks-Oseretsky Test of Motor Profiäency (BOTMP) (Bruininks, 1978).
The Fine Motor Composite and The Short Form from this test were used.
The Short Form was included as a brief survey of general motor ability
(Moore, Reeve & Boan, 1986; Verderber & Payne, 1987). It was interpret-
 Motor skills in children with attention deficit hyperactiviry disorder

ed as representing primarily gross motor skills, due to its strong correlation

with the Gross Motor Composite (Broadhead & Bruininks, 1983). The
Gross Motor Composite of the BOTMP was not used, due to its lengthy
administration requirements.

Evidence of validity is provided in the test manual in particular in rela­

tion to the correlation of scores with age, internal consistency of the sub-
tests, and ability to discriminate between children with and without
disability. Test-retest and inter-rater reliability are also reported as satis­
factory.

• Quick Neurological Screening Test (QNST) (Mutti, Sterling & Spalding,

1978). This measure includes 15 brief tasks drawn from procedures usually
included in a pédiatrie neurological examination. It was included to pro­
vide information about the neurological basis of motor skill findings. The
test manual reports that the QNST is able to discriminate between chil­
dren with and without learning disability, has reasonable test-retest relia­
bility and is found to correlate with other evaluations of children such as
teachers' ratings and medical/neurological examination.

The remaining measures reported (intellectual ability, achievement,

ADHD severity) were collected by other staff of the ADD Clinic within a
three month time span surrounding the motor assessment.

Analysis
The proportion of children showing scores within defined categories was cal­
culated for parent ratings of motor skills, the BOTMP and the QNST. Corre­
lational analyses were conducted over all variables, including a weighted
measure of ADHD severity derived subsequently from ADD Clinic ratings of
symptom severity. The weighted measure was based on DSM-IIIR criteria and
reflected the parent's report about the presence of each symptom. The weights
available were: Not Present (1); Sometimes Present (2); Present Quite a Lot
(3); Constant Feature (4).

A series of independent sample t-tests was used to investigate differences

in the performance of children usually medicated versus those not usually
medicated.

Results
Approximately one third of the children were judged by their parents to be
uncoordinated on ratings of both gross and fine motor skills. Of those judged
to be uncoordinated, most fell in the 'mild' category, with only 3% drawing
Doyle Wallen and Whitmont

the 'very uncoordinated' rating. By contrast, the parents' judgments of hand­

writing were more extreme: 58% fell in the categories of 'poor' or 'very poor'
(see Table 3). Fewer children were considered well coordinated on the general
ratings for fine motor skills, than were considered well-co-ordinated for gross
motor skills, indicating gross motor skills were considered a relative strength.
Only five percent were rated above average for handwriting.
TABLE 3: Parent ratings of gross motor, fine motor and handwriting skills

Category Gross motor Fine motor Handwriting Category*

% children % children % children

Well coordinated 34 18 5 Above average

Average coordination 34 47 37 Average
Mildly uncoordinated 18 26 *
Moderately uncoordinated 11 5 47 Poor
Very uncoordinated 3 3 11 Very poor

* 4-point scale used for rating

handwriting.

Table 4 shows the Means and Standard Deviations for the several Bru-
ininks-Oseretsky Test of Motor Proficiency scaled scores. For the Fine Motor
Composite and the Short Form (estimating gross motor skills), only 8% and
5% respectively fell in the 'Below Average' range. More children fell in the
'Above Average' category on the Short Form than on the Fine Motor Com­
posite, again suggesting stronger gross motor skills. Direct paired sample t-test
comparison of means indicates a significant difference, with better perfor­
mance in the gross motor domain (t = 3.797, p = 0.001).
Performance on the Quick Neurological Screening Test was consistent

TABLE 4: Bruininks-Oseretsky Test of Motor Proficiency: Scaled scores

Fine motor Short form* Response Visual motor Upper limb

composite* speed** control** speed and
dexterity**

Mean 76 86 21 19 16
(S.D.) 27.22 23.18 6.79 3.54 5.83

Proportion of sample children in given performance categories

Above average 61 82 68 53 26
Average 32 13 21 45 50
Below average 8 5 11 3 24

* Standardisation sample mean = 50..S.D. = 10

**Subtests of the Fine Motor Composite; Standardisation sample mean = 15, S.D . = 5
 Motor skills in children with attention deficit hyperactivity disorder

with the BOTMP outcome (particularly the Short Form), revealing a neuro-
logically intact sample for the most part. In brief, 84% of the sample fell in
the normal range. A moderate, significant association was noted between the
two scales of the BOTMP and the QNST (see Table 5). Qualitatively, QNST
items presenting the most difficulty for children with ADHD were the Left-
Right Discrimination task and Behavioural Irregularities (41% and 35%
falling in the 'Suspicious' or 'At Risk' categories, respectively).
TABLE 5: Quick Neurological Screening Test: Classification of participant children and
association with the BOTMP

Mean* 17
S.D. 9.04

Performance categories **
Normal (0-25) 84%
Suspicious (26-50) 16%
High Risk (>50) 0%

Bruininks-Oseretsky
Fine motor Short form
Correlations*** -0.39 -0.49
QNST x BOTMP (f> = 0.02) (p = 0.003)

* Scale range: 0-148; higher scores indicate less competence; 0-25 considered normal.
** Proportion of participants ailing in each QNST category.
*** Negative association: competency indicated by high scores on BOTMP, low scores on
QNST.

In the correlational analysis, parent ratings of gross motor coordination

were significantly associated with both BOTMP Short Form (r = -0.46,
p < 0.05) and QNST (r = 0.40, p < 0.05), suggesting that parents can predict
general gross motor ability in their children. Parents were not accurate raters
of fine motor skills as the association between their ratings and the children's
BOTMP Fine Motor Composite failed to reach significance. Two other out­
comes were of interest in the correlational analysis. First, ADHD severity
(summed DSM-III item weights) was not associated with any of the remain­
ing variables, with one exception: this was the association between ADHD
severity and parent rating of handwriting skill (r = 0.42, p <0.05). Second, age
was related (weak but significant) to scores on the BOTMP Fine Motor Com­
posite (r = -0.34, p<0.05).
Finally, the main variables of interest were compared between two groups
of children: those usually medicated versus those not usually medicated. Table
6 shows Means and Standard Deviations for selected variables: none were sig­
nificantly different using independent samples t-test comparisons. A parallel
analysis included only those children who were usually medicated, comparing
those withdrawn for assessment versus those assessed while medicated. This
Doyle Wallen and Whitmoht

post facto analysis found a significant group difference for only one motor
variable: BOTMP Short Form performance was better in the group medicated
during assessment.

TABLE 6: Variables of interest by usual medication status

Variable Medicated group Not-medicated group

Mean S.D. Mean S.D.

Age (Total months) 113.32 15.87 115.90 12.67

Severity ADHD (DSM-IIIR) Sum of weights 40.2 8.4 39.8 7.4
CBCL' Total problems t-score 70.6 7.1 68.3 9.4
Handwriting (parent rating) 2.6 0.8 2.6 0.7
QNSTSumof raw scores 15.6 10.1 17.6 7.9

BOTMP Standard scores

Fine motor composite 80.7 24.9 71.8 29.4

Short form 90.3 21.1 82.2 25.0

'Child behaviour checklist

DISCUSSION
This study found several outcomes of importance. First, an unexpectedly low
proportion of children with ADHD showed motor difficulties on objective,
standardised measures. Barkley (1990) estimates over 50% of samples will
show motor difficulties, but in the present sample less than 10% showed
'Below Average' scores on the BOTMP. This could be explained by several
factors, including the possibility that the extent of motor involvement has
been generally overestimated through relying on non-standardised tests, clini­
cal judgment, or parent report. The impression of clumsiness, for example, is
easily confounded by hurried, impulsive activity. Another very real possibility
is that a predominantly inattentive subtype of children with ADHD (not pre­
sent in the current sample) are those most at risk for motor involvement. Any
suggestion that the BOTMP is insensitive to a form of motor difficulty experi­
enced by children with ADHD seems unlikely, in view of the wide range of
motor skills demanded for BOTMP performance. Other explanations, which
may be discarded on the basis of correlational analyses and/or direct compari­
son, are medication status and ADHD severity. A remaining possibility is that
the relatively old BOTMP (1978) scaled scores and categories overestimate
motor ability due to sample cohort effects. This can be answered by inclusion
of a normal control group and is currently under investigation (Whitmont &
Clark, in press).
A second important outcome of the study is that the Australian sample
shows the same profile reported for samples of children with ADHD in other
parts of the world; that is, relatively poor handwriting skills on parent report
 Motor skills in children with attention deficit hyperactivity disorder

and generally better gross than fine motor performance (Stewart et al., 1966;
Szatmari et al., 1989). Children in the present sample had significantly poorer
BOTMP Fine Motor Composite scores than they did Short Form scores (the
Short Form was used to estimate gross motor skills). Although a standardised
measure of handwriting skill was not used, parent ratings suggested that hand­
writing was the most dysfunctional of the motor domains (58% rated as 'poor'
or 'very poor')· While the meaning of this profile is not entirely clear, the
finding is consistent with the suggestion that fine motor skills (especially
handwriting) make greater demands for sustained attention and effortful
activity, capacities which are already problematic in the child with ADHD.
The third major finding of the study is that there was a clear discrepancy
between parent ratings of coordination and the standardised scores. There are
two potential sources of such a discrepancy. First, there may be a difference
between a child's ability and performance: the child may appear to be clumsy
(based on hyperactive, impulsive and inattentive behaviour), but not actually
be clumsy as a result of motor dysfunction. In brief, the symptoms of ADHD
may interfere with the presentation of adequate motor performance. This
position is supported by the fact that parents in the present study rated hand­
writing as the most dysfunctional motor domain. Handwriting is a particularly
complex skill which demands not only fine motor competence but also age-
appropriate achievement (reading, spelling, language), attention, and sus­
tained effort.
Parent rating of handwriting was the single variable to show a significant
association with ADHD severity, indicating poorer handwriting in the pres­
ence of more severe ADHD symptomatology. Continuing interference from
ADHD symptoms might well impede the development of motor skills through
a relative lack of practice. Consistent with this, age in the present study was
inversely associated with motor competency on the Fine Motor Composite
(BOTMP).
A second source of discrepancy (between parent reports of coordination
and the results of standardised measures) might be explained by performance
variables in controlled versus uncontrolled environments. Standardised assess­
ment contexts are extremely structured: measures are paced by the examiner
and consist of brief, achievable tasks conducive to the maintenance of atten­
tion and effort by children with ADHD. Accordingly, the present outcome
may indicate that children with ADHD do not suffer inherent motor impair­
ments, even though they are believed to do so by their parents and may in
fact display apparent difficulties in non-structured settings. Real delays in
complex motor skills such as handwriting may eventually emerge in associa­
tion with lack of practice over time.
Medication effects on motor performance were examined in two ways. The
first analysis of children usually-medicated versus those not usually-medicated
failed to find any difference in motor performance for any of the variables
measured. Post facto analysis showed that motor performance in usually-
Doyle Wallen and Whitmont

medicated children assessed when medicated was similar to performance in

usually-medicated children assessed when not medicated, with one exception:
medication during assessment led to slightly better performance on the
BOTMP Short Form only (p < 0.03).
That measures of fine motor skills were unaffected by medication in both
analyses is consistent with the literature suggesting the stimulants have their
greatest motor effect indirectly through enhanced effort and sustained atten­
tion. However, the idea that medication status is unrelated to BOTMP or
QNST performance generally must be regarded with caution, since medica­
tion status at the time of assessment was not studied systematically (in fact, it
varied with changing ADD Clinic policy over the two year period).

Implications for further study and for clinical practice

Recommendations for future research include a study of larger sample size
with inclusion of a normal control group. An objective measure of handwrit­
ing needs to be used; and use of the BOTMP Gross Motor Composite (as dis­
tinct from the Short Form estimate) might be revealing. Recently developed
measures of motor skills with modern normative data should be considered as
well, for example the new Movement ABC (Henderson & Sugden, 1992).
Finally, there are clear implications of the ability-performance hypothesis
for motor skill remediation in the ADHD population. It is acknowledged that
ADHD symptoms are variable and may be absent in a new or one-to-one
situation such as during occupational therapy assessment (Clark et al., 1989).
Assessment in a structured clinical situation should determine whether the
basis of a child's motor problems is due to underlying coordination difficulties
or factors associated with ADHD symptomatology. That is, when children
with ADHD are referred to occupational therapy with queries regarding motor
performance, the results of clinical observations and standardised assessments
will determine whether or not the child has a motor coordination difficulty.
Discrepancy between parent and teacher concerns of motor performance
deficits, and adequate performance as assessed in the clinical situation, will
alert the therapist to the possibility that the ADHD signs of inattention and
impulsiveness are the basis of these perceived motor difficulties.
Where the basis of motor problems is deemed to be related to the signs of
ADHD, it is unlikely that the usual occupational therapy programmes for
motor skills difficulties will be most effective. It may be useful to use some
motor intervention to boost self-esteem and motivation in relation to motor
activity. It is likely to be most beneficial, however, to assist children to devel­
op strategies to control behaviour, modify impulsiveness, develop self-control
and improve attention and effort to task. Each home, school and community
situation in which the child is required to participate may need to be analysed
to determine what factors may be influencing their motor performance. These
factors may be able to be modified, in addition to applying and generalising
 Motor skills in children with attention deficit hyperactivity disorder

strategies learned to promote attention and concentration to each of these sit­

uations. This type of intervention approach can be implemented in conjunc­
tion with treatment of underlying coordination problems, depending on the
outcome of the assessment.

ACKNOWLEDGMENT:

The authors are grateful to Dr Karen Bythe for her invaluable assistance with
the statistical analysis for this study.

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Address for correspondence: Margaret Wallen, Department of Occupational Therapy, The

Children's Hospital, Westmead NSW 2145, Australia.