Arch Dis Child 2001;85:371–374 371 Neurological soft signs in mainstream pupils Arch Dis Child: first published as 10.1136/adc.85.5.371 on 1 November 2001. Downloaded from J M Fellick, A P J Thomson, J Sills, C A Hart Abstract psychiatry. Are there any tests that a paediatri- Aims—(1) To examine the relation be- cian may use to predict which children have tween neurological soft signs and meas- significant problems? ures of cognition, coordination, and Neurological soft signs (NSS) may be behaviour in mainstream schoolchildren. defined as minor abnormalities in the neuro- (2) To determine whether high soft sign logical examination in the absence of other fea- scores may predict children with signifi- tures of fixed or transient neurological disor- cant problems in other areas. der.1 They have been associated with Methods—A total of 169 children aged behaviour,12 coordination,3 and learning diY- between 8 and 13 years from mainstream culties.4 Other authors believe they represent a schools were assessed. They form part of developmental lag rather than a fixed abnor- a larger study into the outcome of menin- mality.5 Studies have found a high incidence of gococcal disease in childhood. Half had soft signs in children following premature6 or previous meningococcal disease and half low birthweight7 birth, meningitis,8 and malnu- were controls. Assessment involved trition.910 measurement of six soft signs followed by There are a number of soft sign batteries assessment of motor skills (movement published that include tests of sensory func- ABC), cognitive function (WISC-III), and tion, coordination, motor speed, and abnormal behaviour (Conners’ Rating Scales). or associated movements.11 12 Some have been Results—Children having an age cor- validated and tested longitudinally.12–14 Tests rected soft sign score above the 90th may be performed quickly in the clinic centile were considered to have an excess situation and do not require special equipment. of soft signs. When compared to the other We aim firstly to examine the associations children they had significantly worse between NSS and measures of cognitive ability, scores on the other three measures. motor performance, and behaviour in a group Median movement ABC score was 15.3 v of mainstream school children; and secondly to 7. Mean total IQ scores were lower by 10.3 determine whether NSSs may be used to points. Median behaviour scores were sig- predict significant problems in other areas. nificantly higher on both parental and teacher questionnaires. A soft sign score Methods above the 90th centile had a sensitivity of SUBJECTS http://adc.bmj.com/ 38% for detecting cognitive impairment, A total of 169 children, aged between 8 and 13, 42% for detecting coordination problems, attending mainstream school in Merseyside and 25% for detecting possible attention were assessed. They were part of a larger study deficit hyperactivity disorder. into the neurodevelopmental outcomes of Conclusion—In this group of children meningococcal disease (MCD) in childhood. higher scores on the soft sign battery were Half had suVered previous MCD and half were related to significantly worse performance controls. on measures of cognition, coordination, on September 24, 2021 by guest. Protected copyright. and behaviour. However, although soft ASSESSMENTS Institute of Child sign assessment may be of interest it can- These took place at the Royal Liverpool Health, Royal not accurately predict which children are Children’s Hospital (RLCH) or at school, Liverpool Children’s likely to have impairment in other areas. depending on preference. All tests were per- Hospital NHS Trust, (Arch Dis Child 2001;85:371–374) formed by the research fellow following appro- Eaton Road, Liverpool priate training. Written consent was obtained L12 2AP,UK Keywords: neurological soft signs; ADHD; learning J M Fellick diYculties; developmental coordination disorder prior to testing. Approval was gained from the A P J Thomson RLCH and local research and ethics commit- tees. Testing took approximately 1.5 hours to Department of Paediatricians in the UK are increasingly being complete and was performed in the same order Paediatrics, Royal throughout. Liverpool Children’s asked to assess children in mainstream school Hospital who are not performing as well as their peers. J Sills DiVerential diagnoses include developmental Neurological examination coordination disorder, specific or general A standardised neurological examination of Department of learning diYculties, and behaviour problems cranial and peripheral systems was performed Medical Microbiology, such as attention deficit hyperactivity disorder including assessment of power, tone, and University of Liverpool C A Hart (ADHD). Frequently children may have prob- reflexes. Any children with focal neurological lems in all three areas. Neurological examina- signs were excluded from the soft sign analysis. Correspondence to: tion is usually normal and subsequent assess- Dr Fellick ment is time consuming and may involve Soft sign assessment [email protected] multiple agencies such as education, occupa- Six neurological soft signs were assessed Accepted 6 July 2001 tional therapy, and child and adolescent following the protocol devised by Shafer and www.archdischild.com 372 Fellick, Thomson, Sills, Hart Arch Dis Child: first published as 10.1136/adc.85.5.371 on 1 November 2001. Downloaded from Table 1 Raw data Mirror Involuntary Stereognosis Graphaesthesia Dysdiadochokinesis movements Motor speed movements Median 0 0 6 4 72 0 Interquartile range (IQR) 0–0 0–1 3–8 2–6 64–80 0–1 Range 0–3 0–3 0–14 0–12 47–145 0–4 Spearman correlation to total score 0.24 0.51 0.65 0.61 0.69 0.64 colleagues.12 The signs assessed were stereo- complexity. Raw scores are age corrected and gnosis, graphaesthesia, dysdiadokokinesis, expressed as standardised scores (mean 100, mirror movements, motor speed, and involun- SD 15). tary movements. For each subject scores were obtained for each individual soft sign and a Behaviour total summary score was calculated. High The long form of Conners’ Rating Scales, scores indicate more soft signs. Revised (CRS-R)18 was administered to the child’s parent/guardian and to their teacher. The Movement ABC15 These scales are designed to assess ADHD and This is a battery of tests designed to assess related behavioural problems. The questions motor and coordination skills in children. The relate directly to the Diagnostic and Statistical test involves eight tests of motor function Manual of Mental Disorders, Fourth Edition (three of manual dexterity, two of ball skills, (DSM IV). Age standardised t scores (mean and three of static and dynamic balance). The 50, SD 10) are produced for each behaviour battery is age standardised and results in an type, with scores over 70 indicating a possible overall impairment score between 0 and 40, problem. with high scores indicating poorer function. Scores above the 95th centile are considered to Demographics indicate definite motor problems. In addition to the behaviour scales, parents completed demographic questionnaires to de- The Wechsler Intelligence Scale for Children, third termine social class, family size, and type of edition UK (WISC-IIIUK)16 housing (owned/rented) for each case. The first eight subtests of the WISC-IIIUK were administered. Verbal (VIQ), performance STATISTICAL ANALYSIS (PIQ), and total IQ (TIQ) scores were Age adjusted total soft sign scores were calculated and expressed as standardised calculated for each case. Subjects with scores scores (mean 100, SD 15). above the 90th centile were considered to have an excess of soft signs. Bivariate analysis Test of visual–motor integration (VMI)17 compared these cases to the remainder using This test evaluates the ability to copy a either the t test for independent samples or http://adc.bmj.com/ sequence of geometric forms of increasing the Mann–Whitney U test, depending upon the level of data. Analysis was performed on 45 SPSS. 40 Results 35 SOFT SIGN DATA Table 1 summarises the raw soft sign data on September 24, 2021 by guest. Protected copyright. 30 available. The sensory soft signs (stereognosis 25 and graphaesthesia) were rarely present and have lower correlations to total soft sign score. 20 Involuntary movements were also rarely seen, 15 but when present correlated highly with total Number of cases score. Total soft signs scores were inversely 10 related to age in a linear fashion (Pearson coef- ficient −0.4, p = 0.01). Scores were therefore 5 age corrected using linear regression. 0 Figure 1 shows a histogram of corrected soft 0–0.5 0.5–1 1–1.5 1.5–2 2–2.5 2.5–3 3–3.5 3.5–4 4–4.54.5–5 5–5.5 5.5–6 >6 sign scores. Soft sign scores up to 3.5 were nor- Soft sign score mally distributed. Cases with scores greater Figure 1 Frequency histogram of soft sign scores. than 3.5 were considered to have an excess of soft signs (n = 18, 10% of total). There were no Table 2 Relation between coordination skills and soft signs significant demographic diVerences in terms of social class, family size, and type of housing Normal High soft signs between those with high and normal soft sign Movement ABC (n = 151) (n = 18) p value* scores. Manual dexterity, median (IQR) 4.5 (2.0–7.0) 10.0 (7.3–11.4) 0.000 Ball skills, median (IQR) 1.0 (1.0–3.0) 3.0 (1.0–5.3) 0.004 RELATION TO MOVEMENT ABC Balance, median (IQR) 1.5 (0.0–3.0) 3.8 (1.4–6.8) 0.003 Table 2 compares median movement ABC Total, median (IQR) 7.0 (4.0–11.0) 15.3 (11.1–23.1) 0.000 scores for patients with and without excess soft *Mann–Whitney U test. signs.