Does the combination of physical activity and attention training affect the motor skills and cognitive activities of individuals with mild intellectual disability?

Abstract

Individuals with mild intellectual disability (MID) were worse than their peers who typically develop in motor skills and attention-demanding assignments. In this study, effect of a 14-week physical activity and attention training practise on the motor skills, visual retention, perception and attention levels of students with MID were analysed. Twenty-two individuals between 7 and 14 ages participated voluntarily. Activities based on developing attention skills and physical activities enhancing fine-gross motor skills (40 + 60 min./2 days/14 weeks) were given to the experimental group. d2 Test of Attention, Benton Visual Retention and Bruininks-Oseretsky Test of Motor Proficiency-2nd version tests were used as data collection tools. There was significant difference in terms of total number of items processed, commissions, raw score of errors, total number of items minus error scores, concentration performance, Benton visual retention test and perception, fine motor skill precision, fine motor skill integration, manual dexterity and upper-limb coordination values regarding group and time dependant (p< .05). However, there was no significant difference in omissions and fluctuation rate values (p> .05). As a result; it is determined that the combination of physical activity and attention training practises features a positive effect on visual retention, perception, attention and motor skill levels of students with MID.

Introduction

Mild intellectual disability (MID) is a neurodevelopmental disorder (Iwase et al. 2017, Kang 2021) affecting motor skills (Iwase et al. 2017) and cognitive activities (Mungkhetklang et al. 2016). Normal development of individuals with MID are delayed due to cognitive or physical disabilities (Rintala and Loovis 2013). One of the reasons for the delay is that the sense organs and parts of the body do not move consonant with one another. This incompatibility disrupts body coordination (Hartman et al. 2010, Kang 2021). Impaired coordination results in scarcity of basic motor skills like walking, running, and throwing (Wuang et al. 2008, Wouters et al. 2020). Motor skill deficiencies negatively affect the physical characteristics (Top and Akıl 2018), independent behaviours (Blomqvist et al. 2013, Jeoung 2018), and daily lifestyle skills (Cantone et al. 2018) of individuals with MID.

Sub-factors of motor development include fine motor integration, fine motor precision, dexterity, upper-limb coordination, which are effective on fast, accurate and controlled movement (Zwicker and Harris 2009). Fine motor skills are crucial for early learning and development (Pitchford et al. 2016). It is significant for individuals with MID to eliminate fine motor skill deficiencies so as to achieve their daily lifestyle skills. Although there were findings that fine motor skills were improved by physical activities performed on individuals with MID (Top 2015), it had been stated within the study that it might not be enough to eliminate fine motor skills deficiencies only by physical activities, alongside cognitive functions and learning areas should be developed together (Vuijk et al. 2010). In the study of Hartman et al. (2010) stated that although individuals got lower scores in locomotor skills than the individuals with borderline intellectual functioning, there was no difference in object control skills and that they also indicated that motor skills and cognitive activities should be developed together.

It was emphasised that physical activities attentively enhancing activities are important in terms of developing attention and visual memory of students with MID. Regular participation in physical activity has many intellectual benefits (Etnier et al. 2006). With physical activity, blood flow to the brain and oxygenation increased (Swain et al. 2003, Moriarty et al. 2019). The rise within the brain contributed to cognitive functions, selective cognitive activities (Chang et al. 2014) and enhances cognitive performance, learning and memory (Vaynman et al. 2004, Vaynman and Gomez-Pinilla 2005). Physical activity regulated this cognitive functioning through neuroplasticity (Pastula et al. 2012). The task of visual memory which is one among the cognitive activities, is to be ready to relate visual sensation and perception with future actions (Rac-Lubashevsky and Frank 2021). Although it had been shown in the study that there was a strong conceptual link between visual memory and motor skill (Schneegans and Bays 2017), Pecher (2013) found no evidence between motor skills and visual working memory. Rolfs et al. (2013) showed that hand and eye movements link visual attention to focus on positions during movement preparation. In another study, it was stated that when attention, movement (action) and memory cooperate, capacity limitations within the field of vision were exceeded (Kristjánsson and Draschkow 2021). Eye and hand movement physical activities’ increasing attention (Hanning and Deubel 2018, van Ede 2020) may have contributed to the event of visual memory (Hanning et al. 2016). Because there are studies showing that focus is firmly attached to movement (action) (Montagnini and Castet 2007, Messinger et al. 2021). Individuals with MID experience much greater inability to plan behaviour, switch between cognitive behaviours, and make purposeful behaviour than typically developing peers (Oka and Miura 2008, Chen et al. 2009). Lack of attention is at the centre of this inadequacy. There is a strong relation between lack of attention and learning, perception and motor functions in individuals with MID (Djuric-Zdravkovic et al. 2010). For this reason, activities which will increase attention can contribute to visual memory, perception, attention and motor development of individuals with MID.

Physical activity contributes to motor development and lifestyle skills of individuals with MID (Top et al. 2015, Top and Akıl 2018). Attention training studies also support visual memory, perception, and motor development in individuals with MID (Simonoff 2007, Wulf et al. 2010, Wuang and Su 2011). Although physical activity or attention training practises performed alone contribute to individuals in terms of attention, memory, perception, and motor development, when the above studies are examined thorough, it’ll be seen that these effects are limited or may be do not have effects in some studies (Gall et al. 2018). Information about individuals with MID is restricted. The consequences are going to be far more limited if individuals with MID are considered to be far behind their peers who show typical physical and cognitive development. When effect of neurological conditions like systema nervosum and degenerative disorders of the muscles on motor skills (Lanza et al. 2020a, Lanza et al. 2020b) and cognitive activities and effects of some alternative and complementary therapies on cognitive decline (Lanza et al. 2018) were analysed, it had been observed that combination of physical activity and attention training could contribute more to the individuals with MID. For this reason, physical activity and mindfulness training practises can contribute positively to individuals with MID. Because it had been shown in studies that dual-task training interventions were far more effective on motor skills and cognitive functions (Falbo et al. 2016, Santner et al. 2018). Additionally, independent mechanisms that direct attention to eye and hand targets (physical activity or attention exercises) can further increase this effect by interacting separately with working memory (Nissens and Fiehler 2020). Therefore, we tried to check the subsequent hypotheses in our research: (a) Does a combined study in which attention developing exercises and activities are applied together, improve the visual memory and perception of students with MID? (b) Does a combined study feature a greater impact on attention? (c) Can the combination of attention-based activities and exercises improve motor skills more?

Material and methods

Participants

Sample group consisted of totally 22 students with MID, living in Turkey, 11 subjects in experimental group (N = 11; five girls, six boys, M_(Age)= 11.26 ± 2.03 years, M_(Height) = 143.45 ± 13.59 cm, M_{(body weight)} = 38.61 ± 13.05 kg, BMI_{(kg/(height)2}= 18.33 ± 4.43) and 11 in control group (N = 11; seven girls, four boys, M_(Age)= 11.33 ± 1.63 years, M_(Height)=139.09 ± 12.42 cm, M _{(body weight)} = 35.07 ± 9.34 kg, BMI_{(kg/(height)2}= 17.73 ± 3.34) between 7 and 14 age. The method of selecting groups and implementing activities is given in Figure 1. Individuals with MID who had no second barriers (vision, hearing, and bodily) which may prevent their participation in attention training practises, and no health problems that might prevent their participation in physical activity (heart disease, epilepsy, diabetics, etc.) were included within the study. The individuals who had disease and took drugs which prevented school activities and participated in any structured exercise programme within the last 6 months were not included in the study. School management, teachers, individuals with MID and their families were informed intimately about the content, purpose, method, location, time and duration of the study. Families signed consent form for participation. Individuals whose visual memory, perception, attention, and motor skill levels were determined, were divided into experimental (n = 11) and control (n = 11) groups by random sampling method.

Figure 1.

Selection stages of groups and activity application.

Wechsler Intelligence Scale for Children-Revised (WISC-R) IQ was applied to the individuals with MID who participated in the study by Counselling and Research Centre. Specialists identified that individuals were in the category of MID. Intelligence quotient (IQ) scores of individuals with MID were in the 50–70 range. The study was conducted in accordance with Helsinki Declaration and it was approved by the University Non-Interventional Clinical Research Ethics Committee, Faculty of Medicine (139-02-16) and Provincial Directorate of National Education.

Body measurements

Participants' heights were measured by employing a Seca brand stadiometer as cm with a sensitivity of 0.01 cm on the bare feet, heels during a combined position, body upright and head Frankfort plane. Body weight was measured as kg by a Seca electronic scale with a sensitivity of 0.01 kg when the participants had light clothing on bare feet. Wıthin the calculation of Body Mass Index (BMI), dividing height by weight method was used (kg/(height)².

Physical activity and attention training application

The physical activity and attention training practises applied within the research were administered for 14 weeks, 2 days a week. 100 min. (40 + 60 min.) were given for each activity. Within the first 40 min of the programme, activities that improve attention, perception and visual memory were made (painting, cutting, sorting, line up), in the remaining 60 min, physical activities that improve motor skills (running, dribbling, coordination trails, station work, games) were included. Attention spans of students with MID are shorter than students with typical development. Thanks to the fact that their span was short and make them benefit more, training period was decided 40 min divided in two sections as 20 min (Kirk et al. 2016). The applications were structured in such a way that one researcher and a couple of assistant instructors, who are experts in attention trainings and tests, accompanied during classroom environment and all students did the same activity together. Instructors used enthusiastic, positive and clear expression throughout the sessions. It had been ensured that their attention was on the activities they did. It was considered that the tables and chairs in the classroom were ergonomic, there was a certain distance between the students, there were no extracurricular materials in the environment that would distract the student, and there was no noise (Janeslätt et al. 2019, Grigorenko et al. 2020, Guillomía et al. 2021). During the 40-minute activities aimed toward improving attention, perception and memory, students were informed about the important points and reminded just in case during the applications. In the 60-minute part of our study physical activities, phases of warming up, application and cooling down were included. Within the warming up phase (10 min.), they were asked to jog and do stretching activities (5 min.) then application was carried out (40 min.) and therefore the training was finished with cooling. Physical activity practises were administered by the researcher and a couple of trainers in the field of sports education. The students in the control group were not given any activities. Physical activity cards and activities that improve attention getting skills of the Ministry of National Education were utilized in the preparation of the physical activity and attention training programme (Ministry of National Education General Directorate of Basic Education 2012). The activity programme was prepared to allow individual practises and group activities to be administered from time to time by taking into consideration the children's developmental levels and motor skills.

Data collection tools

Bruininks-Oseretsky test of motor proficiency-second version (BOT-2)

Data were collected by Bruininks-Oseretsky Test of Motor Proficiency-2nd Version (BOT-2) (Bruininks and Bruininks 2005). BOT-2 was created to measure motor functioning of the individuals from 4 to 21. It is an appropriate testing tool for individuals with MID. It is utilized in various countries to work out motor development. Internal consistency and reliability of the test is pretty good (Wuang and Su 2009, Bertapelli et al. 2020). BOT-2 is an instrument employed by educators, therapists and researchers to measure the motor skills of children, prepare a motor development programme, analyse them, detect and evaluate various motor dysfunctions and developmental retardations. It consists of 8 subtests, and 53 items. The duration of the test can change between 40 and 60 min for every individual. During the study, 4 subtests were applied: Subtest 1: Fine Motor Precision (7 items). Subtest 2: Fine Motor Integration (8 items). Subtest 3: Manual Dexterity (5 items). Subtest 4: Upper-limb Coordination (7 items) (Bruininks and Bruininks 2005). Motor skill tests were administered in sequence in physical education courses in the school's gymnasium hall. During the tests, students were given motivational verbal instructions like Bravo, Well Done, Very Good! The test was stopped when the student was distracted, bored or unwilling to continue. It was started again when the student was willing to complete. Motor skill tests were administered by the researchers who are experts in motor skill tests and a couple of trainers who are well trained in the field of sports education.

d2 test of attention

Developed by Brickenkamp in 1962 and revised several times in the following years. Aim of the test is to evaluate sustained attention and visual scanning (Spreen and Strauss 1998). It is measurement of selective attention and mental concentration. In the manual of the test the structure of ‘attention and concentration’ was used as continuous, performance-oriented, and a focus on selecting a stimulus (Brickenkamp and Zillmer 1998). Although the d2 test was originally developed to pick the drivers, it is now used to assess attention in various environments like psychopharmacology, education, clinics, sports psychology (Brickenkamp and Zillmer 1998, Oswald and Hagen 1997, Didycz et al. 2018). On the front page of the test, there was a section where the subject's personal information and performance results would be recorded and a physical activity line. The back page contained a standard test form. It consisted of 14 lines with 47 characters in each line. There were 16 different letters in each line, consisting of the letters ‘p’ and ‘d’ with one, two, three and four small dashes. Ignoring other non-related letters, the subject had to scan the lines to find and draw the letters ‘d’, which had two signs during the test. The subject was given 20 s per line. It can be applied on either on individuals or groups (Spreen and Strauss 1998, Brickenkamp and Zillmer 1998). 7 parameters were evaluated based on the d2 attention test. These were: total number of items processed (TN), omissions (E₁), commissions (E₂), raw score of errors (E), total number of items minus error scores (TN-E), concentration performance (CP) and fluctuation rate (FR). The test was applied to students in turn in a quiet classroom at school.

Benton visual retention test

Benton Visual Retention Test (BVRT) is an individually administered, performance dependant test which incorporates various cognitive components like visual perception, visual memory, visual-spatial cognitive abilities and widely used both in clinics and researches (Sivan 1992, Benton 1974, Didycz et al. 2018). Analysing the researches in the fields of medicine, psychology and education, it is observed that there are various researches associated with visual memory (Kulp et al. 2002, Le Carret et al. 2003, Nielson et al. 2014, Whisler 1974, Zappalà et al. 1995). BVRT was used to determine the visual short-term memory capacities of the students involved in the research. Test can be applied to children and adults. It consisted of three alternative forms based on drawing and prepared at equal levels (C, D, E) and four different alternative administration methods (A, B, C, D) regarding these forms. It also included F and G formats which provided opportunity for additional verbal application of the test, and therefore multiple choice recognition-based application method (M) prepared for these forms. Application of the test for F and G formats (Verbal recognition): F, G formats are verbal and includes 15 plans. To use each form, 5 min. was given. The student was asked to try to do this command: ‘Firstly, I'll show you cardboard with an image thereon. After you examine this picture for ten seconds, I'm getting to ask you to seek out the first picture you see on another card with four pictures’. The student could show the image or say its name. During this study, BVRT-F format was used. It was applied during a quiet classroom at school to the students successively. Tests were administered by one researcher and a couple of assistant trainers who were experts in attention training and tests.

Statistical analysis

SPSS 21.0 statistical package programme was used to evaluate the data. p= .05 is considered as significance level in comparisons. Repeated Measures Anova Test was used to analyse group and measurement (2 × 3). When the assumption of sphericity was violated (p < .05) and epsilon was ε > .75 Huynh-Feldt correction, in case of ε < .75 Greenhouse-Geisser was used to analyse the results. Bonferroni Test was used as second level test.

Results

Statistically, it had been observed that there was increase within the parameters of TN (p < .05), TN-E (p < .01), CP (p < .01) and BVRT (p < .01) for experimental group, but within the parameters of E₂ (p < .05) and E (p < .01) there was significant decrease. However, there was statistically no significant difference between two groups in parameters of E1 and FR (p > .05; Table 1).

Table 1.

Group x Time Repeated Measurements ANOVA Results related to TN, E₁, E₂, E, TN-E, CP, FR and BVRT

N = 22	Groups	Pre-test M ± SD	Mid-test M ± SD	Post-test M ± SD	F	p	Difference
TN	Experimental (n = 11)	221.00 ± 38.50	264.27 ± 36.47	371.18 ± 41.57	4.487	0.017*	1 < 3, 2 < 3
	Control (n = 11)	186.36 ± 38.50	195.00 ± 36.47	240.55 ± 41.57
E1	Experimental	40.36 ± 9.81	46.82 ± 13.99	40.64 ± 13.52	2.693	.080	–
	Control	19.91 ± 9.81	29.18 ± 13.99	46.36 ± 13.52
E2	Experimental	47.18 ± 7.60	36.00 ± 8.54	29.55 ± 9.85	4.196	0.043*	1 > 2, 1 > 3, 2 > 3
	Control	40.91 ± 7.60	42.09 ± 8.54	56.46 ± 9.85
E	Experimental	58.69 ± 4.77	31.50 ± 4.80	20.11 ± 3.97	23.030	0.000**	1 > 2, 1 > 3, 2 > 3
	Control	40.46 ± 4.77	47.21 ± 4.80	43.67 ± 3.97
TN-E	Experimental	133.46 ± 29.57	181.46 ± 25.70	301.00 ± 32.54	16.843	0.000**	1 < 3, 2 < 3
	Control	125.55 ± 29.57	123.73 ± 25.70	137.73 ± 32.54
CP	Experimental	51.36 ± 9.72	62.73 ± 8.55	113.64 ± 10.00	17.149	0.000**	1 < 3, 2 < 3
	Control	56.27 ± 9.72	52.91 ± 8.55	51.18 ± 10.00
FR	Experimental	17.00 ± 3.02	21.09 ± 2.43	20.46 ± 3.40	0.435	0.622	–
	Control	12.73 ± 3.02	14.00 ± 2.43	17.91 ± 3.40
BVRT	Experimental	6.00 ± 0.91	8.82 ± 0.67	10.82 ± 0.63	39.986	0.000**	1 < 2, 1 < 3, 2 < 3
	Control	6.73 ± 0.91	6.00 ± 0.67	5.91 ± 0.63

**p < .01, *p < .05; TN: Total Number of Items Processed, E₁: Omissions, E₂: Commissions, E: Raw Score of Errors, TN-E: Total Number of Items Minus Error Scores, CP: Concentration Performance, FR: Fluctuation Rate, BVRT: Benton Visual Retention Test

There was statistically significant increase for experimental group in parameters of FMP and ULC between pre-test and mid-test, pre-test and post-test values, also in parameters of FMI and MD pre-test and mid-test, pre-test and post-test and mid-test and post-test (p < .001; Table 2).

Table 2.

Group x Time Repeated Measurements ANOVA Results related to FMP, FMI, MD and ULC

N = 22	Groups	Pre-test M ± SD	Mid-test M ± SD	Post-test M ± SD	F	p	Difference
FMP	Experimental (n = 11)	20.73 ± 2.20	26.91 ± 1.90	29.82 ± 1.79	88.257	0.000*	1 < 2, 1 < 3
	Control (n = 11)	24.00 ± 2.20	21.18 ± 1.90	19.82 ± 1.79
FMI	Experimental	19.18 ± 2.44	24.82 ± 2.23	27.64 ± 2.19	95.546	0.000*	1 < 2, 1 < 3, 2 < 3
	Control	20.73 ± 2.44	19.36 ± 2.23	18.82 ± 2.19
MD	Experimental	12.64 ± 1.81	17.46 ± 1.59	21.91 ± 1.61	63.615	0.000*	1 < 2, 1 < 3, 2 < 3
	Control	17.09 ± 1.81	14.55 ± 1.59	14.46 ± 1.61
ULC	Experimental	14.64 ± 2.41	20.27 ± 2.24	23.82 ± 2.30	118.050	0.000*	1 < 2, 1 < 3
	Control	20.27 ± 2.41	18.27 ± 2.24	15.55 ± 2.30

*p < .001, FMP: Fine Motor Precision, FMI: Fine Motor Integration, MD: Manual Dexterity, ULC: Upper-Limb Coordination

Discussion

It was determined that there was significant difference in favour of experimental group consistent with total number of items processed, total number of items minus error scores, concentration performance, commissions, raw score of errors, Benton visual retention test, fine motor precision, upper-limb coordination, fine motor integration, manual dexterity results. In their study, Ruscheweyh et al. (2011) indicated that there was positive correlation between prefrontal, cingulate cortex and brain-derived neurotrophic factor levels and grey matter volume, the correlation increased by physical activity improved memory and retention. Physical activity helps the development of these associations (Ploughman 2008). In a study in which effect of a 12-week physical activity on cognitive functions in individuals with Down syndrome, retention and attention was measured, it was observed that although it had positive effects on retention, it had no effect on attention (Ptomey et al. 2018). In physical activity programme applied to individuals with MID, it was witnessed that there were also significant changes in frontal brain regions, but no changes in cognitive behaviour were observed despite the fact that motivational conditions increased (Vogt et al. 2012). Only physical activity training was applied on those individuals, but in our study attention enhancing activities were also included. For this reason, visual memory, perception and attention can be further enhanced with the support of attention-enhancing activities. During a similar study, participants were given cognitive tasks together with physical activity, and specific cognitive areas, ‘registration and recall’, ‘attention’, ‘verbal fluency and understanding’ and ‘visuospatial skills’ were significantly improved only within the combined training group (Yokoyama et al. 2015). It is a crucial finding in terms of showing that the co-execution of physical activities with attention-enhancing activities proves that individuals with MID can improve their attention and visual memory levels more.

It was observed that the physical activity programme, which was applied with attention-enhancing activities, increased motor development. Motor skills are actions taken by the individual towards the goal, and they are needed to carry out a purposeful activity (Hartman et al. 2010). In this respect, individuals with MID show lower motor coordination than their typically-developing peers and have difficulty in fine and gross motor skills (Cantone et al. 2018). Extra sportive studies are proposed to finish those disabilities (Rintala and Loovis 2013). Sports activities contribute to the motor development of individuals with MID, and there is a relationship between motor development and cognitive functionality (Vuijk et al. 2010, Ślężyńska et al. 2018). Therefore, activities that enhance motor development and cognitive performance together are proposed (Hartman et al. 2010). In a study comparing the motor skills of individuals with MID, borderline mental disabilities and normal development, the lowest locomotor levels were found in individuals with MID. There was a positive relationship between object control skills and playing sports between peers with MID and normal development (Westendorp et al. 2011). In a study comparing the motor skills of 82 different students with intellectual disability (ID) aged between 11 and 20 (borderline ID 11; mild ID 27; moderate ID 19; 10 people with autism), children with MID scored lower than all in motor skills. As a result, it is stated that there is a relation between intelligence and motor development (Jeoung 2018). Also, there is a relation between physical activity, motor development and attention. Making physical activities develops attention, cognitive function, memory, and motor skills through metabolic, neurochemical, and neural mechanisms (Brehmer et al. 2012, Lauenroth et al. 2016). Enhanced attention increases quality of movements (Alesi et al. 2018). Especially combined physical and cognitive activities give better results (Wollesen and Voelcker-Rehage 2014). This can be interpreted as the fact that physical activity programmes can affect motor development more but their co-implementation are going to be simpler in motor development.

In our study, hand and eye movements like painting, cutting, sorting, arranging were applied as attention-enhancing activities. The aim of this application was to supply deciduous attention improvements reported on eye and hand targets, which were thought to be caused by effector-specific feedback loops between the front parietal and posterior areas (Hanning and Deubel 2018, Bamford et al. 2020). Supporting attention could further increase the impact on cognitive activities, because it is confirmed within the study that only physical activity does not have an impact on attention (Gall et al. 2018). For this reason, attention enhancing activities were included in the study. There are evidences that the event of attention supports visual memory, perception, and motor skills in individuals with MID (Simonoff 2007, Wulf et al. 2010, Djuric-Zdravkovic et al. 2010, Wuang and Su 2011). The more attention decreases the more motor development rises. As motor development increases, children's level of functionality rises, their interests and skills appear, they develop environmentally appropriate behaviour and it becomes easier for them to live comfortably in society (Chen et al. 2019).

The most important limitations of our study were intervention time (14 weeks) and frequency (only 100-minute lessons twice a week). In addition, unequal sample sizes are present in groups; but given the amount of individuals with MID in society, it can be said that a good number was reached, and experimental and control groups with fairly close physical characteristics were created. Another limitation in our study was the chosen test methods. Using test methods and devices by which even the little changes are often identified for the studies during which this kind of effect is predicted could also be important in terms of defining effect more clear. The very fact that individuals participated within the study have MID can affect the reliability of results in responses to tests. In addition, domestic activities outside the tutorial environment might be more controlled. Although all participants and their families were warned and monitored about this, a study during which all participants' activities are controlled could also be healthier in terms of achieving a result.

Individuals with MID, like other individuals with intellectual disability, do not develop normally thanks to the complex interaction of cognitive, sensory and motor systems in their brains. In our study, individuals with MID made activities with attention-enhancing activities and gained significant benefits in visual memory, perception, attention and motor skills. The findings support causal evidences of the physical activity which explains the relationships between motor skills and cognitive development in children with MID. Considering the studies within the literature, conducting a search with larger representative samples, longer and more advanced testing methods in the future could also be important in terms of supporting our study.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Disclosure statement

All the authors have no conflict of interest related to this article.