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International Journal of Developmental Disabilities logoLink to International Journal of Developmental Disabilities
. 2021 Jul 20;69(2):248–255. doi: 10.1080/20473869.2021.1953940

Fine motor skills and attention level of individuals with mild intellectual disability getting education in inclusive classrooms and special education schools

Elif Top 1,✉
PMCID: PMC10071985  PMID: 37025344

Abstract

In this study, the difference between fine motor skills and attention levels of children with mild intellectual disabilities (MID) who get education in inclusive classrooms and special education schools and the relationship between fine motor skills and attention levels were analysed. A total of 176 children with MID between the ages of 9–14, who get education in inclusive classrooms (n = 96) and special education schools (N = 80), participated in the study. Bruininks–Oseretsky Test of Motor Proficiency-Second Version (BOT-2) and Bourdon Attention Tests were applied as data tools. Fine Motor Precision (FMP), Fine Motor Integration (FMI) and Attention levels of the children in inclusive classrooms were higher than those who get education at special education schools (p < .05). In all parameters of the children of inclusive classrooms and special education schools (except the parameters of FMP-6: Folding Paper and FMI-8: Copying Overlapping Pencils), there was a positive correlation between attention and fine motor skill values (p < .05). The fact that children with MID get inclusive education with typically developing peers contributes more to these individuals in terms of fine motor skills and attention parameters. However, more extensive work is needed in this field.

Keywords: inclusive education, fine motor skill, attention, intellectual disability, special, education, school

Introduction

Intellectual disability (ID) is a neurodevelopmental disorder that affects interpersonal relationships and practical skills and leads to limitations in motor skills (Tomaz et al. 2017, Memisevic and Djordjevic 2018, Kang 2021). The prevalence of individuals with ID within the world population is 1–3%. The majority of individuals with ID are in the mild intellectual disability (MID) category (85%). The most common population is in childhood and adolescence (Maulik et al. 2011, McKenzie et al. 2019). The motor development level of individuals with MID is lower than that of typically developing peers (Rintala and Loovis 2013, Yan et al. 2021). In a study, individuals with MID got lower scores in fine motor skills than typically developing peers (Simons et al. 2008). Attention contributes to the development of fine motor skills (Brehmer et al. 2012, Lauenroth et al. 2016). Well-developed fine motor skills facilitate children’s cognition and attention development (Piek et al. 2008, Pitchford et al. 2016) and contribute positively to daily life activities (Shin et al. 2015). More stimuli that develop attention in the educational environment also support motor development (Grooms and Baumeister 2019). Spending time in a classroom environment is important for individuals to observe different social behaviours and learn which behaviours are appropriate and acceptable (Smogorzewska et al. 2019). Classroom environment is suitable to establish continuous interactions between children with disabilities and their typically developing peers and it motivates them to make positive changes in various functional areas (Nakken and Pijl 2002). It shows how important the educational environment is for a child with MID to develop and acquire the skills necessary for themselves in daily life activities.

Inclusive practices mean that children with special needs and children with typical development get co-education in non-formal education schools and in the same classroom environment (Black and Hill 2020, Francisco et al. 2020). The aim of inclusive education is to provide opportunity, access, equality and social justice. Although inclusive education has been implemented in many countries since the 1960s, it has been carried out in Turkey since 1983 (Yazıcıoğlu 2018). Inclusive education has been practiced in many countries since the 1960s, but policies on special education in Turkey have been carried out since the 1960s (Melekoglu et al. 2009, Sarı et al. 2020), and policies on inclusive education have been applied since 1983 (Yazıcıoğlu 2018, Sarı et al. 2020). The main aim of the educational activities is to ensure the development of children who need special education or inclusive education (Cakiroglu and Melekoglu 2014).

Some of the goals in inclusion education are to increase the level of functionality of children, encourage them to use their abilities, develop behaviours that are appropriate to the environment, and ensure that the individual can live in the society (Chen et al. 2019). Although inclusive education is shown as a basic need (Luciano and Savage 2007), it is one of the most controversial issues related to the education of children with special education needs (Kauffman and Badar 2014). While some researchers claim that it affects children negatively and it means to sacrifice them (Kauffman and Hallahan 2005), some others report positive opinions about inclusive education and suggest that it could be quite useful (Justice et al. 2014). On the other hand, some others believe that adapting special education schools to meet the needs of the child individually is a more accurate approach (Heath et al. 2004). Besides, it is also suggested that the curricula of inclusive education and special education should be synthesized (Hornby 2015).

As it can be understood from research studies, education is a complex issue, and a number of physical, mental, political and cultural differences need to be considered in order to include individuals in inclusive education (Kavale and Forness 2000, Vaughn et al. 2000, Erten and Savage 2012, Sharma et al. 2019). To identify these differences, inclusive classrooms and special education schools have been compared in various categories and it has been attempted to determine which educational environment is better. Different ideas have emerged in these comparisons and both types of education have been found to be either successful or incomplete (Klicpera and Klicpera 2004, Bode and Hirner 2013). The causes of these differences may be education policy, teacher attitude, financial constraints, and peer influence (Szumski and Karwowski 2012, Klang et al. 2020).

Serious progress has been made during the past 15 years regarding special and inclusive education in Turkey. The main reason is that the Ministry of National Education has expanded its special education services and inclusive education policy by giving priority to them (Melekoglu et al. 2009, Cakiroglu and Melekoglu 2014). Evaluating the results of educational policies applied is crucial because children in inclusive education participate in activities such as physical activity as much as their typically developing peers, while they are less involved in some practices such as math and science (Eriksson et al. 2007). The main difference here may be due to the applied school curriculum or the quality of the education provided. In inclusive education, children get education with typically developing peers in a normal classroom, while an individualized education program is applied to children in special education schools (Yazıcıoğlu 2018). These different educational practices can also significantly affect the development of the child (Szumski and Karwowski 2014) because comparative studies in which two different educational environments are examined indicate that children with MID who are placed in inclusive educational environment show better performance in terms of social competence (Freeman and Alkin 2000), reading, writing (Dessemontet et al. 2012) and life skills (Smogorzewska et al. 2019) than the children in special education environment. The main reason for this may be the child’s effort to act together with his/her peers (Blick et al. 2015). Although both training environments are compared according to many factors, studies that evaluate attention and fine motor skills development are rare. The effort of the children with MID who have 50% lower mobility and motor activity than their peers (Westendorp et al. 2011), to move along with their typically developing peers may further improve their fine motor skill or attention. Because attention and motor development parameters are factors that support each other, they are also affected by the educational environment (Wulf et al. 2010). In our study, we tested the hypothesis. Is there any difference in the level of fine motor skills and attention between children with MID who get inclusive education and children with MID who study in a special education school? Is there any difference in terms of attention and motor development levels between children with MID who get inclusive education and children at special education schools? Thus, the information obtained by examining children with similar characteristics in both educational environments can contribute to the development of education and school preferences of children with MID.

Methods

Participants and ethics approval

The study was approved by the Social Sciences and Humanities Ethics Committee of Usak University with 2020 decision date and 96 registration number. It was carried out in accordance with the Declaration of Helsinki. About 25 schools providing inclusive education and 2 special education schools were identified after official correspondence with the Provincial Directorate of National Education. Contacts were established with the principals of these schools and meeting days and hours were decided. As a result of meetings with school principals, classroom teachers, families and specialists of the Guidance Research Centre, a total of 176 children between the ages of 9 and 14 who met the following criteria were included in the study. Socio-demographic characteristics of the children participating in the study were given in Table 1. Before the application of the study, the necessary permissions were obtained by informing the school administrators and the families of the participants about the scale and tests to be applied.

Table 1.

Socio-demographic information of the individuals.

Groups Special education schools
M ± SD
 Inclusive classrooms
M ± SD
Gender (N) Female (N = 30) Male (N = 50) Female (N = 24) Male (N = 72)
Age (years) 10.87 ± 2.01 11.24 ± 1.89 11.79 ± 1.38 10.83 ± 1.73
Height (cm) 139.67 ± 13.97 146.18 ± 13.82 150.17 ± 12.44 147.72 ± 13.77
Body weight (M ± SD) (kg) 38.03 ± 11.68 41.80 ± 16.76 43.78 ± 10.60 45.67 ± 35.80
Body mass index (kg/height)2 19.18 ± 3.91 19.01 ± 5.44 19.26 ± 3.21 18.35 ± 4.49
Intelligence scores (IQ) (N = 100) 61.43 ± 2.81 62.49 ± 2.84
Drawing hand-right (N) 28 42 21 64
Drawing hand-left (N) 2 8 3 8
Intelligence score ranges 50–70 50–70
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There were criteria for participation in the research: (1) Being a student in inclusive classroom and special education school; (2) Having intelligence quotient (IQ) score between 50 and 70 and being diagnosed as individual with MID; (3) Not having vision, hearing and physical disabilities that will prevent him/her from participating in the tests; (4) Being at the age of 9–14; (5) Being able to do exercises shown and required; (6) Going to school regularly. Those who had disease and took drugs that prevented school activities and those who participated in any structured exercise program in the last 6 months were not included in the study.

Research design

Comparative scanning model among relational scanning methods was used in the study. The dependent variable of the study was the score taken from the tests. Maximum diversity model which is one of the random sampling methods was used. In this model, special care was given to the fact that children with MID from every age group were taken at even and body mass indices (BMIs) were close to each other since it could affect motor development. IQ levels of the groups were intended to be at the same level because it could affect their attention and school activities. Children whose behavioural and social involvement levels were similar were included in the study in collaboration with the family, the Guidance Research Centre and teachers.

Body measurements

Jawon brand (Jawon Make; Model IOI-353) body composition analyser was used to determine body measurements. The analyser had a system (frequency: 5, 50, 250 kHz) in which the barefoot contacts, had a clean steel surface and analyses from leg to leg. Measurements were taken at 0.1 sensitivity, barefoot and with light clothing on them. Participants’ BMI was calculated by dividing height by body weight (kg/(height))2.

Intelligence level

Wechsler Intelligence Scale for Children-Revised (WISC-R) intelligence test was applied on the children who participated in the study by the experts at the Guidance and Research Centre. According to the intelligence test results, it was determined by the experts that they were in the category of MID. Children’s IQ scores were in the 50–70 range. The official disability report included an explanation of the type and degree of disability. However, there were no detailed results regarding IQ, but parents could request them separately. As a result of the information given by the families who shared their children’s IQ scores, there was no significant difference between groups, t(100) = −1.875, p = .064 (inclusive classroom: M = 62.49, SD = 2.84; special education school: M = 61.43, SD = 2.81).

Application of the tests

School administrators of the students who were identified as students of the inclusive classroom and special education school were contacted, the necessary permissions were obtained, and the days and hours to make measurement were decided. The students who would be measured were met on the determined day and time. Students were taken from the classroom environment in which they studied, accompanied by their teachers, to the classroom environment in which measurements would be made. Students were applied firstly the Bourdon attention test, then the fine motor skills tests. During the tests, it was noted that the classroom environment was empty and quiet, the students’ motivation was high. In addition, the students were verbally motivated during the tests.

Data collection tools

Bruininks–Oseretsky Test of Motor Proficiency-Second Version (BOT-2)

Bruininks–Oseretsky Test of Motor Proficiency-Second Version (BOT-2) was developed to measure motor functions of the individuals in the age group 4–20 years (Bruininks and Bruininks 2005). BOT-2 is a proper testing tool for individuals with IDs. It is used in many countries to determine the motor development of children and studies have shown that the internal consistency and test reliability of the scale is very well (Wuang and Su 2009, Bertapelli et al. 2020). The duration of the BOT-2 long form per an individual was between 40 and 60 min. It totally consisted of 8 subtests and 53 items. Subtest 1 and subtest 2 of BOT-2 which were related to fine motor skills were used in the study. These are: Subtest 1 Fine Motor Precision (FMP) (7 items): 1. Filling in Shapes-Circle (FMP-1), 2. Filling in Shapes-Star (FMP-2), 3. Drawing Lines Through Paths-Crooked (FMP-3), 4. Drawing Lines Through Paths-Curved (FMP-4), 5. Connecting Dots (FMP-5), 6. Folding Paper (FMP-6), 7. Cutting out a Circle (FMP-7). Maximum score in the subtest 1 was 41. Subtest 2 Fine Motor Integration (FMI) (8 items): 1. Copying a Circle (FMI-1), 2. Copying a Square (FMI-2), 3. Copying Overlapping Circles (FMI-3), 4. Copying a Wavy Line (FMI-4), 5. Copying a Triangle (FMI-5), 6. Copying a Diamond (FMI-6), 7. Copying a Star (FMI-7), 8. Copying Overlapping Pencils (FMI-8). Maximum score in the subtest 2 was 40. It took approximately 15–20 min for the test to be administered per a person (Bruininks and Bruininks 2005).

Bourdon attention test

The latest version of Bourdon Attention Test was B. It was developed by Bourdon in 1955. It can be applied to the individuals between the ages of 9 and 20. The test requires a sustained attention orientation. There are two types of Bourdon Attention Test. In the first type, individuals are expected to find and mark definite letters among the potpourri of letters; in the second version, they are requested to find and mark shapes among the potpourri of shapes. In the test, we applied randomly selected letters on a page given to them. These letters were designed in an order and each page included 660 letters. In a page, there were 31 letters ‘a’, 29 letters ‘g’, 30 letters ‘b’ and 29 letters ‘d’. Students were asked in 3 min to find out and mark the letters a, b, d and g which were interspersed among the other letters. Unmarked or incorrectly marked letters were accepted as errors. In the evaluation of the test, correct answers were regarded and each correct answer was recorded as 1 point. The correlation coefficient for the validity and reliability of Bourdon Attention Test was .78. (Brickenkamp et al. 1975, Karaduman and Özdoğan 2004).

Statistical analysis

Windows IBM SPSS Statistics 21.0 program was used to examine statistical tests. For statistical analysis, the results were expressed as mean values and standard deviation, and p = .05 significance level was taken into account in the comparisons. Parametric tests were used to evaluate the data in the study. Hotelling’s T2 test was used to evaluate the data obtained. Bonferroni test was used in the two comparisons in case of difference between the groups. The correlation between fine motor skills and attention levels of the children in inclusive classrooms and special education schools was analysed by Pearson Correlation Test.

Results

According to Hotelling’s T2 statistics test results; a significant difference was found between the mean vectors in terms of groups (Wilks’ λ = .534, p < .05). According to Bonferroni test results; statistically, FMP total, FMI total and attention scores of the students in inclusive classrooms were higher than those who studied at special education schools (p < .05). In addition, in all FMP and FMI subtests, the scores of students in inclusive classrooms were higher than those who studied at special education schools (p < .05; Table 2).

Table 2.

Comparison of fine motor skills and attention values of the children by school types.

  Special education schools
(n = 80)
 Inclusive classrooms
(n = 96)
  
df (176) M SD M SD p
1. Filling in Shapes-Circle 2.13 0.91 2.79 0.43 .000*
2. Filling in Shapes-Star 1.99 0.93 2.69 0.67 .000*
3. Drawing Lines through Paths-Crooked 3.76 3.04 6.15 1.31 .000*
4. Drawing Lines through Paths-Curved 3.33 2.40 4.45 1.83 .001*
5. Connecting Dots 4.90 1.70 5.65 1.12 .001*
6. Folding Paper 2.00 2.00 3.81 2.32 .000*
7. Cutting out a Circle 3.04 2.65 4.86 2.25 .000*
Fine Motor Precision-Total 21.14 10.59 30.40 7.28 .000*
1. Copying a Circle 2.38 1.53 2.88 1.29 .020*
2. Copying a Square 3.14 2.07 4.22 1.09 .000*
3. Copying Overlapping Circles 2.06 2.50 4.19 1.77 .000*
4. Copying a Wavy Line 1.99 1.84 2.91 1.33 .000*
5. Copying a Triangle 2.83 2.15 4.07 1.22 .000*
6. Copying a Diamond 1.35 1.98 3.64 1.58 .000*
7. Copying a Star 0.61 1.37 2.16 1.98 .000*
8. Copying Overlapping Pencils 0.25 0.99 1.13 2.05 .001*
Fine Motor Integration Total 14.60 10.39 25.18 8.31 .000*
Bourdon Attention Test 18.38 15.20 32.93 21.49 .000*
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*Significant difference <0.05, adjustment for multiple comparisons: Bonferroni.

According to correlation test, there was a positive correlation between FMP total (r = .592, p < .01), FMI total (r = .656, p < .01) and attention parameters of the special education school students. Also, a statistically positive correlation was found between all subtests of the FMP (except FMP-6: Folding paper), FMI (except FMI-8: Copying overlapping pencils) and attention parameter of special education school students (p < .05, Table 3).

Table 3.

Correlation between attention and fine motor skill values of the students at special education schools.

N = 80   FMP-1 FMP-2 FMP-3 FMP-4 FMP-5 FMP-6 FMP-7 FMP-Total  
BAT R .553** .581** .576** .476** .427** .197 .457** .592**  
 
 P
 .000
 .000
 .000
 .000
 .000
 .080
 .000
 .000
  
 
  
 FMI-1
FMI-2
FMI-3
FMI-4
FMI-5
FMI-6
FMI-7
FMI-8
FMI-Total
BAT R .489** .526** .654** .526** .385** .425** .452** .094 .656**
P .000 .000 .000 .000 .000 .000 .000 .407 .000
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**Correlation is significant at 0.01 level, *Correlation is significant at 0.05 level.

BAT: Bourdon Attention Test; FMP-1: Filling in Shapes-Circle; FMP-2: Filling in Shapes-Star; FMP-3: Drawing Lines through Paths-Crooked; FMP-4: Drawing Lines through Paths-Curved; FMP-5: Connecting Dots; FMP-6: Folding Paper; FMP-7: Cutting out a Circle; FMP-Total: Fine Motor Precision-Total. FMI-1: Copying a Circle; FMI-2: Copying a Square; FMI-3: Copying Overlapping Circles; FMI-4: Copying a Wavy Line; FMI-5: Copying a Triangle; FMI-6: Copying a Diamond; FMI-7: Copying a Star; FMI-8: Copying Overlapping Pencils; FMI-Total: Fine Motor Integration Total.

According to the correlation test, there was a positive correlation between FMP total (r = .575, p < .01), FMI total (r = .482, p < .01) and attention parameters of students in inclusive classrooms. Also, a statistically positive correlation was found between all subtests of the FMP, FMI and attention parameter of students in inclusive classrooms (p < .05, Table 4).

Table 4.

Correlation between attention and fine motor skill scores of the students in inclusive classrooms.

N = 96   FMP-1 FMP-2 FMP-3 FMP-4 FMP-5 FMP-6 FMP-7 FMP-Total  
BAT R .368** .389** .297** .308** .327** .595** .474** .575**  
 
 P
 .000
 .000
 .003
 .002
 .001
 .000
 .000
 .000
  
 
  
 FMI-1
FMI-2
FMI-3
FMI-4
FMI-5
FMI-6
FMI-7
FMI-8
FMI-Total
BAT R .215* .232* .385** .343** .239* .311** .317** .451** .482**
P .036 .023 .000 .001 .019 .002 .002 .000 .000
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**Correlation is significant at 0.01 level, *Correlation is significant at 0.05 level.

BAT: Bourdon Attention Test; FMP-1: Filling in Shapes-Circle; FMP-2: Filling in Shapes-Star; FMP-3: Drawing Lines through Paths-Crooked; FMP-4: Drawing Lines through Paths-Curved; FMP-5: Connecting Dots; FMP-6: Folding Paper; FMP-7: Cutting out a Circle; FMP-Total: Fine Motor Precision-Total. FMI-1: Copying a Circle; FMI-2: Copying a Square; FMI-3: Copying Overlapping Circles; FMI-4: Copying a Wavy Line; FMI-5: Copying a Triangle; FMI-6: Copying a Diamond; FMI-7: Copying a Star; FMI-8: Copying Overlapping Pencils; FMI-Total: Fine Motor Integration Total.

Discussion

In the study, it was observed that fine motor skills and attention levels of children in inclusive classrooms were better than those of children in special education schools. Hence, compared to special education schools, it can be interpreted that inclusive education contributes more to motor skills and attention levels in children with MID with the same level of intelligence.

Poor motor skills impair school life and life quality of children with MID (Top and Akıl 2017). Smogorzewska et al. (2019) have stated in their study that inclusive education is beneficial for the cognitive and social development of children with MID and it also contributes to their life quality. It is shown in the study that this contribution may be due to the teacher, the development is achieved because teachers in inclusive classrooms apply a single approach for everyone, not for the needs of each student so they feel themselves compulsory to comply with their peers (Ferguson 2008). In addition, exercise repetitions shown to children with ID before games to do the exercises successful help them to perform these exercises accurately and improve their performance (Capio et al. 2013). Children who participate in movement practices show progress in motor skills, while children who participate in movements at limited level exhibit lower levels of movement automation (Beilock et al. 2002). This may explain the fact that children with MID have improved more than their peers in special education schools due to their efforts to keep up with their typically developing peers by participating in the same type of practices in the classroom because fine motor skills are necessary for daily activities (Memisevic and Hadzic 2013) and help us to adapt everyday life (McDonald et al. 2007). The fact that children with MID and typically developing children in inclusive classrooms do physical activity together in groups, provides significant contributions in terms of learning to do sports, psychosocial benefit and maintaining social contact (Bartlo and Klein 2011, Lante et al. 2011, Blick et al. 2015). Frequent and intensive participation in sport or recreation activities supports fine and gross motor development and contributes to children with MID in many ways (Top 2015, Top et al. 2015, Top and Akıl 2017, 2018). It clarifies the reason why fine motor skills of children with MID in inclusive classrooms develop more than those in special education schools.

Attention is very effective on motor skills and movement. It increases focus on movement. Increased attention in the movement allows higher motor skills to be demonstrated (Peh et al. 2011). The prefrontal cortex, through connections with cortical and subcortical centres, important for movement control, can play an important role not only in cognition but also in motor function (Diamond 2000). It is significant in explaining the correlation between attention and motor development (Tables 3 and 4). Attention deficiencies are common in individuals with IDs (Neece et al. 2011). In our study, the attention levels of children with MID in inclusive classrooms were found to be higher than those who were educated in special education schools (Table 2). It is vital in terms of indicating that the attention levels of children with MID who are doing activity among their typically developing peers improve much more. When motor skill was treated as the external focus of attention and internal focus of attention, it was observed that the external focus of attention (i.e. focusing on the outcome of movement) contributed more to motor skill than the internal focus of attention (i.e. focusing on the movements of the body) (Wulf 2013). The levels of movement that children displayed during their efforts to adapt to their friends in the inclusive environment may have eventually directed their attention from internal focus to the external focus (Emanuel et al. 2008). Showing that the external focus of attention of talented and successful athletes develops more than less talented athletes may explain this outcome (Beilock et al. 2002). Research studies have shown that kinaesthetic feedback generated by directing children to focus on body movements can improve their motor performance (Tse 2019). It shows that two different educational environments offer attention environments which are different from each other. It can also explain slightly different levels of correlation between the two different educational environments and attention (Tables 3 and 4). A study on individuals with MID is important in terms of supporting our idea that the external focus of attention has improved motor skills more than the internal focus of attention (Chiviacowsky et al. 2013).

Even though our study results indicated that education in inclusive classrooms for MID children was beneficial for attention levels and fine motor skill development, the study was limited to a specific region and a small number of children. Relevant to motor development and attention parameters, individuals with MID can get inclusive education in the same classes with their typically developing peers. However, school administrators and teachers at the schools where we conduct the study may have impact on this result because education policy, teacher attitude, financial constraints and peers can affect inclusive education and special education practices. A nationwide standard is necessary to have an effective inclusive program. Only an inclusive program that can be managed in this way can get the desired results. Continuity and consistency are important in learning and this can be achieved through collaboration between teachers. Internal and external focus of attention should also be determined well within the education model used. Finally, we suggest that research studies with larger sample groups and different educational models should be done in the future. Comparing teaching practices in special education schools with those in inclusion classrooms is prominent to identify the strengths and weaknesses of both environments. For this reason, new research studies can be done by including more different features in the studies in which inclusive and special education environments are compared. As a result, more extensive new studies should be done by integrating different features to comparative studies of inclusive and special education environments.

Disclosure statement

No potential conflict of interest was reported by the authors.

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