Xml Test




0









The Indian Journal of Occupational Therapy : Vol. XXXIII : No. 1, April-July

2001



A PRELIMINARY STUDY OF SOMATOSENSORY ABILITIES OF NORMAL SCHOOL GOING



CHILDREN AND CEREBRAL PALSY CHILDREN IN THE AGE GROUP 6 TO 8 YEARS.



USHA BHOJNE, P.V. REGE



Deptt. of Occupational Therapy, All India Institute of Physical Medicine &

Rehabilitation, Mumbai



INTRODUCTION



Within the skin are housed many receptors, which can be



classified as :-



Touch is considered to be very important for normal



development. Tactile exploration becomes associated with



visual exploration early in infancy and the child comes to rely



on both forms of exploration for successful environmental



interaction. (Getman, 1985). Hence poor tactile perception



leads to deficits in tactile discrimination. Aryes (1972 b)



hypothesized that poor tactile discrimination may underline



inadequate fine motor skills because of its possible



interference with manipulative skills.



Mechanoreceptors – Provide information relative to



exploring and manipulating the environment and



determining the texture of the support surface.



Chemoreceptors – Respond to substances released by



cells, including damaged cells following injury or



infection.



Thermoreceptors – Respond to heat or cold.



Tactile perception and proprioceptive input are believed to



make important contribution to the development of body



scheme. Both somatosensory inputs and body scheme are



hypothesized to provide the basis for praxis.



Pathways



Three types of pathway bring sensory information to the brain.



1.



Conscious relay pathway also called as



discriminatory pathway as it provides information



about location and type of stimulus to the cerebral



cortex.



Cerebral Palsy has been defined as motor problem due to



lack of freedom in the choice of movement (Milani-



Comparetti, 1982). It is this lack of freedom of movement,



which prevents the Cerebral Palsy child from exploring the



environment both tactually and visually.



2.



3.



Divergent relay pathway.



Unconscious relay pathway.



Sensory processing problems in Cerebral Palsy children have



been found to be either primary or secondary to their motor



deficits. Most of the sensory integrative deficits and their



evaluation and treatment strategies have been used in children



with minimal brain damaged, or learning disabled children.



Very few studies and research material have been developed



for the Cerebral Palsy population wherein the major emphasis



is placed on the sensory deficits than the motor. Hence this



study was aimed at evaluating the somatosensory deficits in



Cerebral Palsy children.



The pathways involve three projection neurons and travel



through the spinal cord via two routs-Dorsal columns and



anterolateral tracts.



Dorsal column/medial lemniscal system



Dorsal column medial lemniscal system transmits primarily



tactile, vibratory, touch-pressure and proprioceptive



information. They are associated with the functions inherent



in tactile discrimination or preception i.e. detection of size,



form, texture and movement across the skin.



Neuro-anatomical and neuro-physiological



basis of somatosensory system



The skin is the sensory organ subserving the tactile system.



In the brain the dorsal column fibres synapse in the ventral



posterior lateral nucleus of the thalamus and within the



reticular formation. Thalamic interpretation is thought to



permit vague conscious discrimination of tactile input, while



the reticular projections may help in modulating arousal.



CORRESPONDENCE : Dr. Usha Bhojne , Veena

Beena Apts.,



A/402, A.D.Mary, Sewri, Mumbai-400015



E-Mail : ushabhogne@hotmail.com



The paper was presented with KAILASH MERCHANT



AWARD FOR BEST PAPER IN NEUROLOGY in EMCON,



01: The XXXVIII National Conference of AIOTA at



Bhubaneswar, in Jan, 2001.



3









Anterolateral system



of lemniscal pathways at the midbrain in cats was stereotyped



hyperexploratory behavior. The animal was incapable of fine



specialized analysis, and responded to stimulation by a “stormy



defense reaction” the defensive reaction was increased after



section of the posterior columns.



Anterolateral system is composed of 3 separate pathways



that function primarily to mediate pain, crude touch and



temperature. These pathways are spinothalamic,



spinoreticular and spinotectal. Localization of sharp or acute



pain relies on projections to the ventral posterior lateral nucleus



of the thalamus. This nucleus is said to be an important site



for interaction of information as the dorsal column medial



lemniscal system also projects to it and has an inhibitory



influence over the anterolateral system.



Herbert Birch (1963) 9 The

inhibitory systems associated



with the memory system subserve the function of a control



system for self-regulation of sensory intake. The child so



afflicted will be impaired not only in the fund of knowledge



but also in abstracting the class characteristic of a stimulus



pattern from its particularities i.e., to minimize the impact of



its particular size by reducing it towards a standard size and



so on.



Cortical reception areas include the primary and secondary



somatosensory cortex as well as Areas 5 and 7 of the posterior



parietal lobe and is interconnected with the premotor area.



(response preparation area or motor planning areas of the



brain)



Fisher (1964) concluded that females probably have a more



1



definite clear and stable concept of the relationship of



boundaries of their bodies to the perceptual field than to males.



Functional Overlap



Umansky (1973) studied the impact of restricted sensory



information on movement in babies. The results suggested



that young babies are particularly susceptible to ignoring a



body part when sensory information to that body part is



reduced. As a result of this the baby fails to integrate the



body part into the body scheme.



Current research delineates considerable functional overlap



between the dorsal column medial lemniscal system and



anterolateral system. Information about non-discriminatory



(coarse) touch travels in the anterolateral system and some



pain and temperature information ascends in the dorsal region



(Wissis and Loggeshall, 1991).



Meizack. R and Southmayd (1974) in a study conducted



18



Information from the face



in cats with lesions of the dorsal columns found they were



unable to jump over barriers while being carried on a moving



conveyor belt even through they could see the barrier. They



needed the tactile stimulation of their paws making contact



with the bar before they could jump that is, their impairment



pertained to feed forward more than feed back motor control.



Fibres from the Trigeminal nerve carry information to the



medulla and upper cervical cord, they then cross the midline



and synapse on the ventro-posterior medial nucleus of



thalamus and project to the cerebral cortex.



Review of Literature



Vierck C.J. (1978) suggested the dorsal coulmn relay to



18



the motor cortex occurs quickly and appears to specify the



direction of fine distal movements rather than reaction of



entire limb.



Ayres. A.J. (1966) found that difficulty in motor planning



1



might be expected to be accompained by deficits in tactile



perception. Less clear inferences are that a defensive



response to certain types of tactile stimuli and hyper-activity



and distractibility also show a tendency to be associated with



a disordered tactile system.



Jones and Porter (1980)



11



indicated there is a close



association between sensations and motion. There is evidence



that area 5 of the parietal cortex is a major site of convergence



of bilateral proprioceptive input from muscles, cutaneous and



joint receptors of the body. Cells in Area 5 begin firing before



movement is initiated suggesting some of these cells may



play a role in planning active movement. It also has reciprocal



connections with precentral motor areas including the



supplementary motor area further suggesting its role in motor



planning.



Hoop. H.N. (1971) based on studies showed that preschool



10



children prefer to touch and explore an object rather than to



observe. Results suggest that exploratory movements become



more complete and systematic with age and vary according



to the type of object.



Sprague and Assoc. (1963) one of the results of section



9



IJOT : Vol. XXXIII : No. 1



April – July 2001



4









Levine (1985)



18



proposed poor motor planning and motor



California Sensory Integration Test was used for



evaluation as it was comprehensive, could be easily



administred without modification and tested the tactile system



from its simplest form of finger identification to manual form



perception, which involved more abstract interpretation of



tactile input from localization, identification, texture, form and



contour (shape). This makes the exploration through touch



more meaningful by formation of instant visual imagery of



the tactile input being experienced by the individual, which



can only happen through the intact neuronal organization.



memory, somatosensory deficits, inco-ordination, poor form



and space preception and impaired visuo-motor organization



as probable causes for dysgraphia.



Brooks (1986) suggested that vestibular proprioceptive



18



feed back is used in two ways. It regulates ongoing, present



activity and it guides, as part of the motor memory, the



execution of such a task in the future. He also suggested



that body scheme is important to the ability to plan projected



movement sequences.



AIMS AND OBJECTIVES



Curry J and Exner (1988) in a study on 15 normal



7



preschool children and 15 pre school children with Cerebral



Palsy found CP children chose hard objects significantly more



often that they chose soft objects, the normal children had no



such preferences. The apparent preferences of CP children



for hard objects and their avoidance of soft objects suggests



that they may have a decreased tactile awareness and need



the greater proprioceptive input that hard objects provide.



This study indicates that the CP children have somatosensory



deficits, which could markedly affect their hand function.



1.



To study the somatosensory perceptual abilities in brain



damaged children of 6-8 years of age.



Hypothesis



For normal population



H1



H2



There is no differnece in the performance of



somatosensory abilities between girls of age group



6.1-7 and 7.1-8 years.



There is no difference in the performance of



somatosensory abilities between boys of age group



6.1-7 and 7.1-8 years.



Most of the above studies have shown the importance of



somatosensory system in the motor planning and manipulatory



abilities of a normal child however very few studies have



emphasized the importance of this system in a Cerebral Palsy



child’s motor planning and manipulatory abilities. Hence this



study was done to assess the deficits occuring as a result of



poor somatosensory preception.



H3



There is no difference in the performance of



somatosensory abilities between normal school going



girls and boys.



For clinical population



Various tests like De-Gangi Berk’s Test of tensory



Integration, Marianne Frostig’s Visual Preceptual Test have



been developed to assess various sensory deficits like



vestibular proprioceptive, visual preceptual however most of



the tests do not emphasize on the somatosensory system.



Various tests have also been developed to assess isolated



functions of the somatosensory system like Test for



Kinesthetic Sensitivity (Bairstow), Semmes – Winstein’s



Monofilament Test, Double Tactile Stimulation and



Stereognosis Test (Non-Standardised)



H4



H5



There is a difference in the performance of normal



school going children and Cerebral Palsy diplegics.



There is a difference in the performance of normal



school going children and Hemiplegics.



MATERIAL AND METHODOLOY



The sample composed of 100 normal school going boys and



girls and 20 cerebral palsy boys and girls within 6-8 yrs of



age. The study was carried out at Occupational & Therapy



Deptt. of All India Institute of Phy. Med. and Rehabilitation,



Mumbai.



The Ontario School of Occupational Therapy Test for



perception also tests a part of the somatosensory system. It



tests the somatosensory processing and interpretation abilities



in its simplest from but does not have items to test complex



interpretation of the tactile inputs using intersensory



organization.



Subject Criteria



(i)



For normal school going children



(a)



(b)



Age : 6.1-7 and 7.1-8 years.



Sex : both males and females.



Hence the Somatosensory Test Battery of Southern



IJOT : Vol. XXXIII : No. 1



April – July 2001



5









(c)



(d)



No previous or recent history of brain damage



or associated conditions.



Table I



Subject Characteristics of Normals



Intact visual and auditory systems.



Sex



Boys



50



25



25



Girls



50



25



25



Total



100



50



(b)



For clinical group



Age : 6.1-7 and 7.1-8 years.



Age



(a)



(b)



(c)



(d)



6.1 – 7 years



7.1 – 8 years



Sex : both males and females



Cerebral Palsy diplegic and hemiplegic



Adequate trunk control to allow for balanced



sitting posture.



50



Table II



Subject Characteristics of Clinical Population



Boys



(e)



(f)



Cognition : normal or educable



Intact auditory and visual system.



Diagnosis



C.P. Diplegia



Hemiplegia



Sex



Girls



10



3



Total



Age



10



2



3



3



2



10



10



5



5



5



5



10



Out of the sample of 100 normal children 25 girls and 25



boys in each age group were evaluated.



6.1-7 yrs



7.1-8 yrs



6.1-7 yrs



7.1-8 yrs



Total



2



The subjects were assessed on the somatosensory tests of



the Southern California Sensory Integration Test. The tests



are as follows.



2



3



10



1.



2.



3.



4.



5.



6.



Kinesthesia



Manual form perception



Finger identification



Graphesthesia



Localization of tactile stimuli



Double tactile stimuli



Table III



Comparison of Somatosensory abilities between normal



school going girls of age group 6.1-7 years and 7.1-8



years.



The sample was also observed for hyperactivity and tactile



defensive behaviours using the following scale.



Mean



S.D.



4.05



1.417



0.47



3.58



1.91



0



Mean



S.D.



4.07



1.03



0.8



4.60



2.67



0.24



t



Probability



KIN



MFP



FI



89.76



89.5



0.226 N.S.



8.48



15.68



17.08



90.67



32



7.92



1.600



0.223



0.963



0.304



Sig at P0.1



N.S.



Hyperactivity or



Distractibility



Definitely hyperactive and



or distractable



Tactile Defensiveness



15.80



15.96



90.87



31.76



1.



One or more definite or



three or more possibly



defensive responses.



One or two possibly



defensive responses.



No apparent defensive



response.



GRA



LTS



DTS



N.S



N.S.



Slightly more active or



distractable than normal



Normal activity



2.



3.



5



Sig at P0.05



Table IV



Comparison of Somatosensory abilities between normal



school going boys of age group 6.1-7 years and 7.1 – 8



years.



Procedure : Initially the children were interviewed and



evaluated. Information on age, diagnosis, intelligence level,



auditory and visual systems were obtained from medical



records and interview.



Mean



S.D.



Mean



87.72



8.08



15.44



13.52



92.47



32



S.D.



2.62



1.49



1.139



3.38



2.14



0



t



Probability



Sig atP 0.05



Sig at P0.05



N.S.



KIN



MFP



FI



84.42



3.29



3.91



7.2



15.68



12.2



92.88



31.96



1.16



0.732



4.77



2.35



0.95



2.32



1.034



1.139



0.645



0.211



The tests were conducted with examiner sitting on the right



side of the child.



A quiet well-lit room was preferred so as to avoid any



distraction.



GRA



LTS



DTS



N.S



In patients with poor hand functions minimal support was



provided proximally at the wrist or forearm to assist the child



in holding shapes and moving his hand.



N.S.



N.S



No significant difference within the age groups was found



except on the test for manual form perception, which was



common in both the sexes. Hence the Hypothesis H 1 and H2



are rejected.



Data analysis



The data obtained was subjected to statistical analysis.



IJOT : Vol. XXXIII : No. 1



April – July 2001



6









Table V



Comparison of somatosensory abilities between normal girls



and boys of age group 6.1-7 years and 7.1-8 years.



Table VIII



Comparison of somatosensory abilities between



Carebral Palsy diplegic boys and normal school going



boys in the age group of 6.1-7 years.



Mean



S.D.



Mean



86.69



7.81



15.66



14.38



91.16



31.88



S.D.



4.61



5.89



0.88



4.46



2.75



0.47



t



Probability



N.S.



Tests



KIN



MFP



FI



Mean



71.3



0



S.D.



19.37



0



t



Probability



N.S.



KIN



MFP



FI



86.92



7.75



0.917



0.957



7.23



15.68



14.8



91.67



31.98



4.77



0.64



4.92



2.76



0.14



4.212



2.314



3.258



1.747



0.01



Sig at P0.0005



Sig at P0.001



Sig at P0.005



N.S.



30.90



1.647



1.674



4.089



0.211



Sig at P0.0005



Sig at P0.05



Sig at P.05



Sig at P.0005



N.S.



14



1.414



6.363



9.263



0



GRA



LTS



DTS



GRA



LTS



DTS



4.5



54.95



32



N.S



Table IX



A significant difference was found among the performance



of girls and boys. Thus Hypotesis H 3 is

rejected.



Comparison of somatosensory abilities between



Carebral Palsy diplegic boys and normal school going



boys in the age group 7.1-8 years.



C.P. DIPLEGICS



Table VI



Comparison of somatosensory abilities between C.P.



diplegic girls and normal girls in the group of



6.1-7 years.



Tests



KIN



MFP



FI



Mean



S.D.



12.83



2.081



1.527



4.582



2.478



1.732



t



Probability



Sig at P.05



Sig at P0.05



Sig at P0.01



Sig at P.025



Sig at P.005



N.S.



74



1.847



2.666



4.373



2.318



2.388



2.772



1.000



13.33



7



Tests



KIN



MFP



FI



Mean



82.36



30.33



13.33



7



S.D.



6.43



10.154



0.577



6.008



4.75



0



t



Probability



Sig at P0.05



Sig at P0.0005



Sig at P0.0005



Sig at P.005



N.S.



GRA



LTS



DTS



1.884



88.33



31



7.123



6.811



2.814



0.422



0



Differences in the performance of C.P. Diplegics and normal



children within the same age group was found (Table VI,



VII, VIII & IX) with the tests of graphesthesia, finger



identification and manual form perception showing the highest



GRA



LTS



DTS



87.43



32



N.S.



incidence of occurance. Therefore the Hypothesis H is



4



accepted.



Table VII



Comparison of somatosensory abilities between C.P.



diplegic girls and normal girls in the age group of



7.1-8 years.



HEMIPLEGICS



Table X



Comparison of somatosensory abilities between



hemiplegic girls and normal girls in the age group



6.1-7 years.



Tests



KIN



MFP



FI



Mean



86.05



6.5



14



S.D.



5.727



0.707



0



t



Probability



N.S.



Tests



KIN



MFP



FI



Mean



S.D.



15.909



0.707



0.707



1.414



6.929



0.707



t



Probability



Sig at P0.025



Sig at P0.005



Sig at P0.025



Sig at P0.0005



N.S.



0.835



65.15



2.186



3.450



2.322



2.629



11.25



3.176



0.145



0.518



Sig at P0.01



Sig at P0.0005



Sig at P.005



N.S.



6.5



14.5



5



GRA



LTS



DTS



7.5



91.45



31.5



3.535



5.586



0.707



GRA



LTS



DTS



11.124



3.501



7.014



76.6



28.5



N.S.



Sig at P0.0005



IJOT : Vol. XXXIII : No. 1



April – July 2001



7









Table XI



Comparison of somatosensory abilities between



hemiplegic girls and normal girls in the age



group 7.1-8 yars.



DISCUSSION



The somatosensory abilities of the normal girls and boys



between the age groups of 6.1-7 and 7.1-8 years were



compared (Table III & IV). No significant difference was



found in any of the tests except on the tests for manual form



perception, which was common in both the sexes. This could



be attributed to the fact that manual form perception usually



Tests



KIN



MFP



FI



Mean



76.5



6.66



14



S.D.



18.792



1.154



1.732



6.429



7.823



1.527



t



Probability



N.S.



1.194



1.807



1.778



1.210



2.266



2.752



Sig at P0.05



Sig at P0.5



N.S



develops around the age of 6-7 years (Piaget) .



18



Table (V) shows a significant difference between the



performance of girls and boys, which were in accordance to



GRA



LTS



DTS



11.33



80.566



29.33



Sig at P0.025



Sig at P0.005



research, counducted by Fisher (1964) . Differences in the



1



performance of C.P. diplegics and normal children within the



same age group was found (Table VI, VII, VIII and IX)



with the test of graphesthesia, finger identification and manual



form perception showing the highest incidence of occurance.



This may be because finger identification, graphesthesia and



manual form perception require more discriminative neural



processes and are found to have an element of figure ground



and form and space perception. Ayres in 1965 found that



tactile discriminative abilities were associated with visual



perception .



Table XII



Comparison of somatosensory abilities between



hemiplegic boys and normal boys in the age



group 6.1-7 yars.



Tests



KIN



MFP



FI



Mean



74.46



6.666



12.666



5.333



89



S.D.



10.943



0.577



1.527



5.507



1.442



1



t



Probability



Sig at P.10



Sig at P10



Sig at P.005



Sig at P.025



Sig at P0.005



Sig at P0.5



1.567



18



1.329



3.380



2.066



4.058



1.579



It is seen that many of cerebral diplegic inspite of minimal



upper extremity involvement have problems in their functional



activities like buttoning, fastening, eating and writing which



require spatial and temporal awareness and planning.



GRA



LTS



DTS



Ayres (1972) hypothesized that the body scheme is critical



to the ability to motor plan and that processing of tactile as



well as proprioceptive information is of critical importance in



the development of body scheme.



31



Table XVII



Comparison of somatosensory abilities between



hemiplegic boys and normal boys in the age



group 7.1 – 8 years.



A deficit in somatosensory processing thus interferes in the



manipulatory skills leading to inadequate fine motor skills



which could be seen as a low score on manual form



perception in all the age groups in the clinical population.



This is further emphasized by Philips Ashwell that the manner



in which the child explores an object in manual form



perception gives insight into the child’s ability to organise



Tests



KIN



MFP



FI



Mean



68.75



50.5



14



S.D.



10.535



0.707



0



t



Probability



Sig at P10



Sig at P.0005



Sig at P.0005



Sig at P.005



Sig at P0.025



Sig at P.0005



2.540



4.431



6.376



3.591



2.148



7.843



spatial and temporal cues. Ayres (1966) found a tactile-



18



motor planning alliance appearing so clearly in subjects with



deficits in these domains. She termed the developmental



deviation as somato-dyspraxia.



GRA



LTS



DTS



10.5



87.55



28



0.707



3.181



0



A significant difference is seen on comparison of hemiplegic



population in all the six somatosensory tests. The hemiplegic



population inspite of one side of body functioning normally,



showed deficits in all the somatosensory tests in all ages



showing that the side of involvement seems to be irrelevant



with regard to the incidence of sensory disorders.



A significant difference is seen on comparison of scores of



hemiplegic population with the normal population in all the



six somatosensory tests, except for the test on kinesthesia



and graphesthesia, which showed no significant difference



in the age group of 7.1-8 in girls (Table X, XI, XII, XIII)



Hence the Hypotesis H 5 is

accepted.



The normal and clinical populations were also observed for



responses of tactile defensiveness and hyperactivity.



IJOT : Vol. XXXIII : No. 1



April – July 2001



8









None of the groups showed any tactile defensive responses



indicating that tactile defensiveness is not associated with



discriminatory skill. However the clinical population record 2



on the hyperactivity scale as compared to the normal who



scored 3 thus supporting the role of somatosensation in



attention, orientation and anticipation i.e., the ability to plan.



The correlation between the somatosensory score and the



attention and hyperactivity score was found to be significantly



positive (r=0.824).



GRAPH – 1



Comparison of Somato sensory abilities of normal &



clinical population



Normal



C.P.Di.



C.P.Hemi



100



90



80



70



60



50



40



30



20



10



0



However it should be also taken into consideration that the



clinical population scored relatively well in one or two of the



tactile tests and poorly on the other. Hence it could be



concluded that tactile functions are at best difficult to assess



and several should be given to obtain a reliable index of tactile



discrimination.



KIN



MFP



FL



GRA



LTS



DTS



performance of both the clinical groups from



the normals. (Graph)



Some of the test may have additional meaning like for e.g.



manual form perception which tests the kinesthetic, tactile,



and visual perceptual processes wherein the tactile and



kinesthetic input is processed and the response is through



formation of visual imagery and indicating it on the test plate



of geometric forms. Thus a low score on Manual Form



Perception tells about the child’s intersensory integration but



not very much about the tectile system or about kinesthesia



exclusively.















Manual form perception showed the highest



significance of difference in the clinical



population showing the role of somatosensations



in interpretation of physical characteristic of the



received information.



The hemiplegic population showed significant



difference in all the test suggesting the



importance of interhemispheric functions and



the treatment of a hemiplegic child as a whole



rather than single sided involvement.



The low score of the clinical population on the



hyperactivity and attention scale shows the



importance of somatosensation in a child’s



academic and daily functioning.



The present study demonstrated the complex role of



somatosensations on a child’s functioning. However in this



sample it was not possible to predict such performance solely



on the age, sex or somatosensory functions per se, as



independent functioning also depends on integration of other



sensory modalities, motor components and motivation of the



child. Further research with larger population is recommended



to set up a more precise data and to find whether



somatosensory deficits can be a significant predictor of poor



manipulatory and exploratory skills and attention.



Thus taking into account the above results the occupational



therapists can use some clinical strategies regarding the



treatment and use of adaptive equipments and toy choices.



Most of the management strategies are geared towards the



motor development of a Cerebral Palsy child wherein the



emphasis is not placed on the sensory deficits hence it can



be inferred that the therapist while treating a cerebral palsy



child should also stress on techniques which improve sensory



processing abilities which would ultimately lead to refined



motor output. Techniques like brushing, compressions push



and pull activities, sandwich games that involve total body



contact and active movements can help to improve somato



CONCLUSION



A study was conducted on 100 normal school going children



and 10 cerebral palsy diplegics and hemiplegics respectively.



1.



2.



To set up a normative score.



To compare the differences between the



somatosensory abilities of normal and brain



damage children.



To study the role of somatosensations on



manipulatory skills and attention.



sensory processing abilities .



12



Adaptive tools with firm padded handles or toys, which are



firm and nonsqueezable, may be needed so that the child



gets adequate tactile and proprioceptive feed back, helping



in easy handling of equipment and to acquire cognitive skills



3.



The somatosensory test battery of Southern California



Sensory Integration Test was used for evaluation.



that accompany object manipulation .



7







There is significant difference in the



performance of girls and boys on the tests with



girls performing better.



The subject sample tested in this study was very small. This



could have increased the likelihood of sampling error and



decreased statistical power. Thus, in the future research with







There was significant difference in the



a larger population over a long period of time is recommended.



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April – July 2001



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