RESEARCH PAPER

A comparison of motor abilities and perceived self-efficacy betweenchildren with hearing impairments and normal hearing children

BATYA ENGEL-YEGER & DAPHNA WEISSMAN

Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Israel

Accepted January 2008

AbstractPurpose. The present study evaluates the differences in motor abilities and in self-efficacy between children with hearingimpairments and children with normal hearing.Method. Participants were 48 children, aged 5 – 9 years, including 22 with hearing impairments and 26 with normalhearing. Motor abilities were evaluated by the Children Activity Scales for Teachers (ChAS-T) and the MovementAssessment Battery for Children (MABC). Self-efficacy was evaluated using the Perceived Efficacy and Goal Setting System(PEGS).Results. Children with hearing impairments showed significantly lower motor abilities, according to the ChAS-T and theMABC. No significant differences were found between the groups in regard to the self-efficacy level according to mostevaluated scales. Results for the study group revealed a significant correlation between the ChAS-T and the static balancescore of the MABC. In both groups, significant correlations were found between motor abilities and child’s age.Conclusions. While children with hearing impairments may show lower motor abilities, as expressed by the MABC and theChAS-T, their self-efficacy is similar to that of their normal hearing peers.

Keywords: Children, motor abilities, hearing impairments, self-efficacy

Introduction

Deafness, caused by conductive or sensorineural

impairments is the most prevalent sensory disorder

[1,2]. Much evidence suggests that early in life,

auditory input and communication are essential for

the normal development of language, cognition, and

behavior [3]. Children with hearing impairments are

likely to show delays in the production of oral

language as well as in other important aspects of non-

verbal development [4], such as motor development

[5,6]. Motor development is fundamental for the

interface of the child with the external world, for

perception and action [7] and for academic skills

[8,9].

It is well established that in the process of motor

development, it is essential for the sensory and

perceptual systems to be in optimal condition [10].

Most studies on the motor development of children

with hearing impairments report some form of delay.

However, there is disparity regarding the type,

duration, and progressive elements of these motor

delays [6]. Wiegersma and Van der Velde [10] found

deficits in dynamic coordination among children 6 –

10 years old with idiopathic hearing impairments, as

well as deficits in manual skills among children with

hearing loss due to known medical causes, such as

rubella during pregnancy. Dummer, Haubensticker,

and Stewart [11], who examined 200 children with

hearing impairments of varying etiology, reported

deficits in ball skills and in balance performance

among children less than 10 years old. Similar results

were reported by Rine, Robinson, Rice, and O’Hare

[12] in their study of children 3 – 5 years old with

idiopathic sensorineural hearing impairments. Rine

et al. [12 – 14] also emphasized that these motor

deficits are progressive and are more severe among

children who manifest vestibular impairment, in

Correspondence: Batya Engel-Yeger, PhD, Occupational Therapy Department, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount

Carmel, Haifa 31905, Israel. Tel: þ972 4 8288389. Fax: þ972 4 8249753. E-mail: batya@research.haifa.ac.il

Disability and Rehabilitation, 2009; 31(5): 352–358

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa Healthcare USA, Inc.

DOI: 10.1080/09638280801896548

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addition to the sensorineural hearing loss, due to

damage in the vestibular structure of the inner ear.

Another aspect that should be elaborated in regard

to children with hearing impairments is their self-

esteem. Farrugia and Austin [15] found that the self-

esteem of deaf students in public schools is lower

than that of their normal hearing peers. Studies also

emphasize the relationship between poor self-esteem

and motor difficulties [8,9] and indicate that children

who do not acquire fundamental motor skills often

experience a high failure rate in school and may

display poorer social development and a weaker self-

concept than their typically developed peers [16 –

18]. Moreover, motor impairments that accompany

other disabilities have been associated with lower

self-esteem level [9]. Following these studies, more

data is needed about the relationship between motor

abilities and self-esteem among children with hearing

impairments.

One factor related to self-esteem is perceived self-

efficacy, which reflects children’s ability to evaluate

their capacity to perform a task competently [19]. A

strong relationship was found between self-efficacy

and performance [20], particularly in regard to

motor deficits [21,22]. Recent data suggest that the

evaluation of self-efficacy should be based on the

child’s own report. According to the client-centered

approach, children’s self-reports of their own abilities

may serve as authentic data about their functioning,

maximize their involvement in treatment, and

improve the treatment efficacy [20,23].

In summary, studies as well as intervention with

hearing-impaired children have focused mainly on

the development of communication skills [14]. More

data is needed about the motor abilities of children

with hearing impairments, the way they impact

child’s function and participation in daily living and

their relation to self-esteem parameters. The pur-

poses of the present study were: (i) To compare the

motor abilities of hearing-impaired children with

those of normal hearing children by evaluating their

motor performance and assessing their motor abil-

ities in daily life, at kindergarten and school,

according to their teacher’s report; (ii) to compare

the self-efficacy level of these groups in regard to

motor abilities of daily living based on the children’s

reports; and (iii) to examine the correlations between

motor abilities and self-efficacy within the groups.

Methods

Subjects

Participants were 48 children, aged 5 – 9 years, who

live in the northern part of Israel. The study group

included 22 children with bilateral sensorineural

hearing loss due to varying etiology (e.g., idiopathic,

genetic), and the control group included 26 children

with normal hearing.

The study group was made up of eight boys and 14

girls, with a mean age of 6.53+ 1.36 years. These

children were recruited from special schools for

children with hearing impairments (n¼ 13) and from

regular schools which have programs for children

with special needs (n¼ 9) in Haifa, Israel. According

to pure tone audiograms and speech reception

thresholds, 20 of these children suffered from

severe-profound hearing loss (65 dB and above)

and two from bilateral moderate hearing loss (45 – 60

dB). Seventeen of them were diagnosed as suffering

from hearing impairments soon after birth, and five

were diagnosed when they were two years old. Half

the children used cochlear implants (CI), and the

other half used hearing aids. In the CI group,

the operation was performed on six children before

the age of two years and on five children between the

ages of 3 – 5 years.

The control group was made up of 10 boys and 16

girls, with a mean age of 6.56+ 1.41 years, who

study in the regular education system. These

children were recruited by the lab of the Occupa-

tional Therapy Department at the University of Haifa

through an advertisement calling for participation in

a study to evaluate children’s motor abilities. Parents

of the children who met the inclusion criteria were

asked to fill out a questionnaire about their children’s

health status and hearing abilities in order to exclude

hearing impairments or recurrent ear diseases/infec-

tions/middle ear effusion.

Exclusion criteria included developmental delays,

positive neurological findings, chronic diseases and

syndromes, learning disabilities, vision impairments,

and treatment with medications that affect the

functioning of the nervous system.

Instrumentation

Demographic questionnaire. This included data on

family socio-demographic status; child’s health sta-

tus, medications, treatments, para-medical therapies

and familial hearing disorders.

The Children Activity Scales for Teachers (ChAS-T)

[24]. This was designed for use by teachers of

children 4 – 8 years of age in order to provide

information about children’s ability to function

within the context of their natural environment in

regard to motor activities. The questionnaire in-

cludes items that not only relate to gross and fine

motor skills, but also focus on children’s organiza-

tion in space and time during the performance of

activities of daily living (ADL), self-care skills,

mobility, ball skills, play activities, and common

school and preschool activities. The alpha coefficient

Comparison of motor abilities between children with hearing impairments and normal hearing children 353

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for the ChAS-T was determined to be 0.96, and a

correlation analysis revealed significant correlations

(r¼ 0.46 – 0.71, p5 0.001) between the 21 indivi-

dual items of the ChAS-T and the total questionnaire

score. Results of the factor analysis of the ChAS-T

revealed three principal factors: (i) Fine motor

performance (five items); (ii) gross motor perfor-

mance (six items); and (iii) organization in space and

time (nine items). Significant correlations were

found between the final scores on the Movement

Assessment Battery for Children (M-ABC) and the

total scores of the ChAS-T (r¼ 0.75, p5 0.0001).

High values were obtained for internal consistency

(0.96 – 0.94). Children whose mean score ranged

from 1 – 3.42 were categorized as suspected of having

Developmental Coordination Disorder (DCD), and

those who scored 3.43 or higher were categorized as

not having DCD [24].

The Movement Assessment Battery for Children

(MABC) [25]. This is a standardized, individually

administered test that assesses the motor functioning

of children 4 – 12 years of age. The assessment

component of the MABC has two parts: A perfor-

mance test which is designed to be administered

individually and requires the child to perform series

of motor tasks in a standard way; and a checklist

which is designed to be completed by an

adult familiar with the child’s day-to-day motor

functioning.

The test contains a total of 32 items organized into

four sets of eight tasks, each set designed for use with

children of a different age band: Age band 1 – for

children between the ages of 4 and 6 years; age band

2 is for 7 – 8 years old; age band 3 is for 9 – 10 years

old and age band 4 is for children of 11 and 12 years.

In the present study age bands 1 – 3 were used. The

requirements of the eight tasks in each level of the

test are identical. The tasks include three manual

dexterity tasks, two ball skills tasks, and three static

and dynamic balance tasks. Different tasks are

evaluated in each age band. For example, when

assessing gross motor abilities, which include ball

skills and balance abilities, in age band 1 the child is

asked to catch a bean bag; roll a ball into goal; stand

on one leg; jump over a cord and walk with heels

raised. In age band 2, these abilities are evaluated by

the following tasks: The child bounces a ball on the

floor and catches it with the same hand; throws bean

bag into a box; stands on one leg while the other foot

is placed against the side of the supporting knee;

jumps in squares; performs heel-to-toe walking. In

age band 3, the these abilities are evaluated by the

following tasks: The child is asked to throw a ball at

the wall and catch it with both hands; to throw a bean

bag into target box with one hand; to stay balanced

on one foot which is placed on a balance board; to

perform continuous hops forward in 6 adjacent

squares and to steady a ball placed on a board

surface.

Children can score between 0 and 5 on each item,

so that the total score will range from 0 – 40, with

higher scores indicative of increased motor difficul-

ties. Scores above the 95th percentile are considered

to indicate probable motor difficulties. Scores above

the 85th percentile are considered to indicate definite

motor difficulties [25,26].

This test has proven to be a valid and reliable tool

for motor function evaluation (minimum value of

test-retest at any age is 0.75, and inter-rater score is

0.70) and has been standardized in accordance with

age-appropriate norms in the four item sets.

This test was chosen to be used in the present

study because of several reasons: (i) This is one of

the most familiar and common test to evaluate

children’s motor performance in research and

practice; (ii) this is a norm-referenced test of motor

difficulties; (iii) this test has a relatively short

administering time or 20 – 40 min (depending on

the age and degree of difficulty experienced by the

child); and (iv) this test may be used by professionals

with a variety of backgrounds and training from both

the educational and medical fields [25].

The Perceived Efficacy and Goal Setting System

(PEGS) [27]. This uses colorful picture cards that

illustrate 24 tasks essential for daily living and

participation in school. These cards are presented

to the child in pairs, with one picture depicting a

child performing a daily task competently and the

other showing a child demonstrating less compe-

tence. The evaluator reads the statements under each

picture and then asks the child to select which picture

is most like him or her. The evaluator then asks the

child whether the picture is ‘a lot’ or ‘a little’ like him/

her and places the cards into four piles reflecting

the child’s stated competence (‘a lot’ or ‘a little’

like the less competent child or ‘a lot’ or ‘a little’

like the more competent child). The score for each

item ranges from 1 (‘a lot like the less competent

child’) to 4 (‘a lot like the more competent child’).

The PEGS is sub-divided into three subtests: The

first includes five items that refer to self-care; the

second includes nine items that refer to school/

productivity; and the third includes 10 items that

refer to leisure. The manual reports good construct

and content validity. Test-retest reliability ranges

from 0.95 – 0.99, and internal consistency ranges

from 0.92 – 0.98.

Procedure

Ethical approval of the study was received from the

Ministry of Education in Israel. All parents signed a

354 B. Engel-Yeger & D. Weissman

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consent form for the participation of their child in

the study. Participants were evaluated in a quiet

room either in their school or at home. The

parents of all children completed the demographic

questionnaire. Questionnaires filled out by the

parents of children who were evaluated in their

school were returned by the children when

meeting the researcher at school. The teachers

filled out the ChAS-T. All children were evaluated

by the PEGS and MABC (The present study

included only the motor performance test and not

the Checklist).

Data analysis

Non-parametric tests were used to calculate the

significance of the differences between the study

groups, as well as between the genders, using the

Mann-Whitney test, since abnormal distribution was

found in the scores of each group.

Spearman’s correlation was used to evaluate the

correlations between PEGS scores, MABC scores,

the ChAS-T total score and the demographic

parameters such as parent’s education, child’s age,

etc. Probabilities below 0.05 were considered

significant.

Results

Comparisons between children with hearing impairments

and children with normal hearing

ChAS-T. According to the teachers’ report, children

with hearing impairments scored significantly lower

on the ChAS-T than did the normal hearing children

(U¼ 119.0; p¼ 0.004).

MABC. Children with hearing impairments showed

lower motor abilities in all tested items. However,

these differences were significant only in several

items. The total MABC mean score of the

children with hearing impairments was significantly

lower than that of the normal hearing children.

The performance scores of five children from the

study group were found between the 5th and 15th

percentile, expressing probable motor difficulties.

The performance scores of the other six children

from the study group were found at or below 5th

percentile, meaning they showed definite motor

difficulties. No significant differences were found

between the groups in manual dexterity skills. As for

gross motor skills, no significant differences were

found between the groups in the ball skills. In regard

to balance skills, the children with hearing impair-

ments demonstrated significantly lower performance

than the normal hearing children in almost all tested

items (see Table I).

PEGS. No significant differences were found be-

tween the groups in most PETS scales. However, the

children with hearing impairments showed signifi-

cantly higher self-efficacy only in the leisure subtest

(u¼ 187.5; p¼ 0.041) (see Figure 1).

Correlation between ChAS-T and MABC scores among

the children with hearing impairments

A significant negative correlation was found

between ChAS-T and the MABC mean static

balance score (r¼70.499; 0.025). This means

that as the teacher reports better motor performance,

the child performs better in the static balance

subtest.

It should be mentioned that when comparing

between children with a hearing aid and children

with CI, no significant differences were found in any

of the tested parameters.

Correlations between motor scores and demographic

parameters among the normal hearing children

A significant negative correlation was found between

the child’s age and total score of the dynamic balance

MABC subtest (r¼70.535; p¼ 0.005), meaning

that as the child grows, his/her dynamic balance skills

improve.

Table I. Comparison of MABC scores between the groups.

Children with hearing

impairments

Children with normal

hearing

Mann-WithneyMean SD Mean SD

Total mean score of manual dexterity 0.73 0.74 0.46 0.49 228.5

Gross motor skills

Total mean score of ball skills 1.54 1.5 0.96 0.92 230.5

Total mean score of static balance 2.36 1.71 0.59 1.13 103***

Total mean score of dynamic balance 0.95 1.16 0.17 0.44 155**

Total MABC mean score 1.19 0.75 0.53 0.33 120**

**p50.01; ***p50.001.

Comparison of motor abilities between children with hearing impairments and normal hearing children 355

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Children who participated in afternoon extra-

curricular activities showed higher self-efficacy, as

reflected in all PEGS subtests: Self-care (r¼ 0.408;

p¼ 0.035); school productivity (r¼ 0.596;

p¼ 0.001); leisure (r¼ 0.42; p¼ 0.029), as well in

the PEGS total score (r¼ 0.591; p¼ 0.001). A

significant positive correlation was found between

the child’s age and the PEGS total score (r¼ 0.531;

p¼ 0.005), as well as between the child’s age and the

scores of each PEGS subtest: Self-care (r¼ 0.464;

p¼ 0.0017); school/productivity (r¼ 0.463;

p¼ 0.018); and leisure (r¼ 0.447; p¼ 0.022), show-

ing that as the child grows his/her self-efficacy rises.

Correlations between motor scores and demographic

parameters among the children with hearing impairments

No significant correlations were found between

children’s participation in afternoon extra-curricular

activities, with greater participation reflected in

higher self-efficacy. A significant positive correlation

was found between the child’s age and the MABC

manual dexterity score (r¼ 0.546; p¼ 0.009), show-

ing that as the child grows his/her manual dexterity

abilities deteriorate.

Among the CI children, no significant correlations

were found between the age at CI implantation and

the child’s motor abilities and self-efficacy level.

Among the CI children, no significant correlations

were found between the age at implantation and the

child’s motor abilities and self-efficacy level.

Discussion

The present study aimed to elaborate existing

knowledge about the motor abilities of children with

hearing impairments, both during pre-school and

school years, using the MABC as well as a teacher’s

report which provides information about the chil-

dren’s motor abilities in the context of their daily

kindergarten/school environment. In addition, this is

one of the first studies to examine the self-efficacy of

children with hearing impairments according to the

child’s report.

In the present study, the motor abilities of children

with hearing impairments were found to be lower

than those of children with normal hearing according

to the teacher’s reports and the results of the MABC.

Notably, the differences between groups on the

MABC were found only in gross motor abilities,

specifically those that measure balance performance.

These results are consistent with those of other

reports. Rine et al. [12 – 14] also found motor deficits

in children with hearing impairments. Horak et al.

[5] emphasized that children with hearing impair-

ments aged 7 – 13 years demonstrated lower balance

abilities compared to normal hearing children. The

researchers emphasized that these motor deficits are

more severe among children with sensorineural

hearing impairments who also suffer from vestibular

impairment due to damage in the vestibular structure

of the inner ear. In the present study, no specific

evaluations for the function of the vestibular organ

were performed. However, the results indicate that

among children with hearing impairments, balance

skills are more affected than other motor abilities.

Contrary to the results of the present study,

Savelsbergh et al. [28] found that children with

hearing impairments had lower ball skills and slower

reaction time in catching ability than did normal

hearing children. They explained that among chil-

dren with hearing impairments, auditory perception

cannot make a contribution to visual orientation to

objects approaching from outside the initial field of

view. Moreover, a lack of auditory stimulation during

development can lead to deficiencies in the coordi-

nation of actions, such as catching, which are both

spatially and temporally constrained. The opposite

findings of the present study may be attributable to

visual feedback derived from the children’s initial

field of view when catching the ball. It may also be

suggested that the difference in the ball skills score

might be found significant in a larger sample.

In the present study, no significant differences

were found between children with cochlear implants

(CI) and children with hearing aids on the various

measurements. Schlumberger, Narbona, and Man-

rique [3] found that deafness, whether treated by CI

or not, resulted in a delay in development of motor

abilities, specifically in regard to motor sequences

and balance abilities. It should be noted that in the

present study each of these groups consisted of a

small number of participants. Further studies on

larger samples are needed in order to evaluate the

contribution of CI to child’s development.

Interestingly, the present study showed that as

children with hearing impairments mature with age,

their manual dexterities deteriorate. These results

supports the study of Horn, Pisoni, and Miyamoto

Figure 1. Comparison of PEGS mean scores between children

with hearing impairments and controls.

356 B. Engel-Yeger & D. Weissman

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[29], who found that while gross motor scores were

positively related to the chronological age of hearing

impaired children, the opposite trend was observed

for fine motor abilities. These findings suggest that

auditory deprivation may lead to atypical develop-

ment of certain motor skills.

Although the literature emphasizes the strong

relationship between self-efficacy and performance

[20,22], no significant differences were found

between the groups according to most PEGS scores.

In another study on children with sensory impair-

ment in the visual modality due to amblyopia [30],

which used the Pictorial Scale of Perceived Compe-

tence and Social Acceptance for Young Children

[31], no significant differences were found in self-

perceived competence between the amblyopic chil-

dren and children with normal vision. Although the

literature emphasize that children hold a view of

themselves which is unique, valid, and stable [32], it

should be noticed that most models of self-percep-

tion are developmental and propose that children’s

ability to compare their own competence to that of

their peers increases and becomes more accurate

with age [33]. Some research suggests that children

under 9 years of age tend to overestimate their

competence [34]. It may be suggested that in the

present study, the fact that most children were under

the age of 9 accounts for their exaggerated response

regarding their self-efficacy. This was more empha-

sized among the children with hearing impairments.

In summary, there is no consensus regarding the

existence of motor delays and the degree of motor

impairment among children with hearing impair-

ments. Moreover, the focus of evaluation and

treatment for this population is primarily on lan-

guage development [6]. Therefore, it is important

that an evaluation of other developmental aspects,

such as motor abilities be performed as early as

possible. Given the disparity regarding the type and

duration of motor development delay [6], it is also

important to re-evaluate motor function in children

with hearing impairments during the course of their

childhood in order to assure early intervention. Since

most reports emphasize that the critical period of

motor control development is between 4 – 6 years of

age [35,36], intervention to address motor deficits in

children with hearing impairments should be pro-

vided before this age [14].

Hence, the intervention process should focus not

only on performance components, but also on the

tasks and contexts in which the child is expected to

perform [37]. The use of a teacher’s report as well as

child’s self-report may improve our knowledge about

the child’s strategies of coping with the disability.

Although in the present study no significant differ-

ences were found between the groups in their

self efficacy level, inclusion of children in the

measurement of their disability may help them to

take responsibility for their disability management

[38]. Specifically in regard to motor function,

research suggests that therapy may actually have a

more potent impact on a child’s self-efficacy and

willingness to engage in motor activities than on the

physical impairment itself [39]. This kind of inter-

vention may enable the child’s optimal development

and participation in the family, the educational

system, and the social environment.

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Comparison of motor abilities between children with hearing impairments and normal hearing children 357

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