Physical & Occupational Therapy In Pediatrics

ISSN: 0194-2638 (Print) 1541-3144 (Online) Journal homepage: http://www.tandfonline.com/loi/ipop20

Effect of Touch Screen Tablet Use on Fine Motor

Development of Young Children

Ling-Yi Lin, Rong-Ju Cherng & Yung-Jung Chen

To cite this article: Ling-Yi Lin, Rong-Ju Cherng & Yung-Jung Chen (2017): Effect of Touch Screen
Tablet Use on Fine Motor Development of Young Children, Physical & Occupational Therapy In
Pediatrics, DOI: 10.1080/01942638.2016.1255290

To link to this article: http://dx.doi.org/10.1080/01942638.2016.1255290

Published online: 10 Jan 2017.

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PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS
http://dx.doi.org/./..

Eect of Touch Screen Tablet Use on Fine Motor Development of

Young Children
Ling-Yi Lina,b , Rong-Ju Cherngb,c , and Yung-Jung Chend
a
Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan;
b
Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan;
c
Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan;
d
Department of Pediatrics, College of Medicine, National Cheng Kung University, Tainan, Taiwan

ABSTRACT ARTICLE HISTORY

Aim: To investigate the effects of touch-screen tablet use on the Received March
fine motor development of preschool children without developmen- Accepted October
tal delay. Methods: 40 children who used a touch-screen tablet more
KEYWORDS
60 minutes per week for at least 1 month received a 24-week home Touch-screen tablet; ne
fine motor activity program using a touch-screen-tablet. 40 children motor; preschool; child
matched for age (mean = 61.0 months) and sex who did not meet the development
criteria for previous tablet use received a 24-week program consisting
of manual play activities. Motor performance was measured using the
BruininksOseretsky Test of Motor Proficiency. The two-factor mixed
design ANOVA was used to compare performance of the touch-screen
tablet and non-touch-screen tablet groups. Results: Pretest analysis
showed no group differences in motor performance and pinch strength.
At posttest, children in the nontouch-screen-tablet group made signif-
icantly greater changes in fine motor precision (p < 0.001), fine motor
integration (p = 0.008), and manual dexterity (p = 0.003). Conclusion:
Using a touch screen tablet extensively might be disadvantageous for
the fine motor development of preschool children.

Preschool age children demonstrate rapid motor, language, cognitive, social, and emotional
development (Copple & Bredekamp, 2009). In recent years, the worldwide percentage of peo-
ple using screen-based leisure activities is increasing, and the number of children who use
touch-screen tablets expands annually (Christakis, 2014; Common Sense Media,2011; Cristia
& Seidl, 2015). As the time spent using touch-screen tablets increases, the time that preschool-
ers are involved in play and physical activity is decreasing (Cristia & Seidl, 2015). In a recent
report, Common Sense Media (2011) surveyed 1384 parents of 0- to 8-year-olds. They found
that 52% of 5- to 8-year-olds had access to popular media such as smartphones, iPads, or other
tablet devices, and that 22% of parents viewed these devices as a temporary nanny to let the
child play quietly for some time. Touch-screen tablets have become one of the most desired
gifts for children. Digital technology has changed the ways children learn, play, and socially
interact (Tanta & Knox, 2015). A touch-screen tablet with interactive applications attracts
childrens attention and offers them some participation and entertainment (Christakis, 2014).
However, using a touch-screen tablet might positively or negatively affect childrens health

CONTACT Ling-Yi Lin, ScD, Associate Professor lingyi@mail.ncku.edu.tw Department of Occupational Therapy and
Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, University Road, Tainan City ,
Taiwan.
Taylor & Francis Group, LLC
2 L. -Y. LIN ET AL.

and development. If the touch-screen tablet has become an important way to play, or just one
more standard device in the lives of children, examining its effects on child development is
highly important. However, there is little evidence (Kucirkova, 2014; Radesky, Schumacher, &
Zuckerman, 2015) to suggest that using a touch-screen tablet is related to the developmental
skills of young children.
Many daily activities require manipulation skills in both hands. When children manipulate
toys or objects with their fingers and hands, their muscle physiology, joint stability, visual per-
ception, and haptic perception requires a high degree of coordination (Case-Smith & Exner,
2015). In contrast, touch-screen devices require simple basic actions: tapping, double-tapping,
pressing, sweeping, dragging, and zooming (Price, Jewitt, & Crescenzi, 2015). Compared with
actions that involve grasping objects, drawing, and handwriting, the involvement of muscle
strength, coordination, and dexterity are relatively lower when using a touch-screen tablet
(Mangen & Velay, 2010). Researchers suggest that the use of touch-screen devices might lead
to changes in the physiological function of muscle and have a significant effect on the acqui-
sition of fine motor skills (Venetsanou & Kambas, 2010).
Although the touch-screen tablet was released in spring 2010, research on its positive and
negative effects on the health and development of preschool children is limited. The majority
of studies have focused on learning activities for typically developing children (Beschorner
& Hutchison, 2013; Couse & Chen, 2010; Neumann & Neumann, 2014; Kucirkova, Messer,
Sheehy, & Panadero, 2014) or improving social interaction of children with autism (Gal,
Lamash, Bauminger-Zviely, Zancanaro, & Weiss, 2016; Hourcade, Bullock-Rest, & Hansen,
2012). However, only few studies have investigated gestures on touchscreen surfaces (Nacher
& Jaen, 2015; Nacher, Jaen, Navarro, Catala, & Gonzlez, 2015). There is scant published
research on how using a touch-screen tablet enhances the acquisition of fine motor skills in
preschoolers. To provide additional empirical evidence about this question, we investigated
how using a touch-screen tablet for 24 weeks enhanced the fine motor development in typ-
ically developing preschool children compared with children in the nontouch-screen tablet
group performing traditional fine motor tasks for 24 weeks.

Methods

Ethical Considerations
The study was reviewed and approved by the Institutional Review Board of National Cheng
Kung University Hospital (A-ER-102-347). Fliers were used to recruit children and their par-
ents from six preschools. The investigators fully explained the procedures to all of the parents,
from whom written informed consent was obtained before they were enrolled in the study.
The investigators upheld the principle that research should not harm participants. The
principal investigator did not force children to participate in the touch-screen-tablet group if
they had not previously used a touch-screen tablet. All parents of children in the touch-screen-
tablet group agreed to allow their children to use a 20-minute touch-screen tablet applica-
tion daily. We strongly suggested limiting touch screen use to no more than 20 minutes per
day.

Participants
The participants were 80 children without developmental delay (N = 80; boys: 52 [65.0%];
mean age: 61.0 7.6 months) (Table 1). The inclusion criteria were (1) 4872 months old; (2)
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 3

Table . Demographic characteristics of participants.

Touch-screen-tablet Non-touch-screen-tablet
Characteristic M SD or n (%) M SD or n (%) Statistic

Gender
Male (.%) (.%)
Female (.%) (.%)
Age (months) . . . .
Birth order
First-born (.%) (.%) = .
Middle-born (%) (.%)
Last-born (.%) (.%)
Only child (.%) (.%) = .
Hand preference
Right (.%) (.%) = .
Left (.%) (.%)
Mixed (.%) (.%)
BMI . . . . t = .
PPVT-R . . . . t = .
Fathers educational level
High school and below (.%) (.%) = .
Bachelor degree or above (.%) (.%)
Mothers educational level
high school and below (.%) (.%) = .
bachelor degree or above (.%) (.%)
Household income
Average (.%) (.%) = .
Above average (.%) (.%)

Note. M, mean; SD, standard deviation; BMI, body mass index; PPVT-R, Peabody Picture Vocabulary Test-Revised.
p < ..

no previous diagnosis of diseases or disorders related to developmental delays (e.g., cerebral

palsy, chromosomal anomalies or abnormalities, preterm, small for gestational age, and low
birth weight); and (3) attending a preschool. The mean Peabody Picture Vocabulary Test-
Revised (PPVT-R Mandarin Version; Lu & Liu, 1988) score was 116.5 9.0 (range of standard
scores: 91145).
A power analysis was conducted using G Power 3.1, with power set at .80 to detect a
medium-size effect (f = 0.25), assuming a moderate correlation among repeated measures
of .50 and = .05.Seventy-eight participants would be required to achieve adequate power,
on the basis of a priori power analysis conducted using G Power 3.1 (Faul, Erdfelder, Buchner,
& Lang, 2009). The statistical power of the experiment was 0.81.
Children were divided into two groups based on their use of a touch-screen tablet matched
for age and sex. Children who had used a touch-screen tablet more than 10 minutes per day or
60 minutes per week for at least one month, were assigned to the touch-screen-tablet group;
if they did not, they were assigned to the non-touch-screen-tablet group.
Touch-screen-tablet group. The touch-screen-tablet group contained 40 children (26 boys;
14 girls; mean age = 61.0 months; Table 1). All participants had been assessed by a registered
psychologist using the Chinese version of the Peabody Picture Vocabulary Test-Revised. The
mean standard score for the sample was 115.5 8.4.
Non-touch-screen-tablet group. The non-touch-screen-tablet group contained 40 children.
There were 26 boys and 14 girls (men age = 61.0 months). The mean standard Peabody Pic-
ture Vocabulary Test-Revised score for the sample was 117.5 9.6. There were no significant
differences in background characteristics between the touch-screen-tablet and non-touch-
screen-tablet groups, with exception that more children in the touch-screen-tablet group were
an only child.
4 L. -Y. LIN ET AL.

Measures
BruininksOseretsky Test of Motor Proficiency. The BruininksOseretsky Test of Motor
Proficiency-second edition (BOT-2;Bruininks & Bruininks, 2005) was used to examine the
participants fine motor performance. The BOT-2 is a norm-referenced standardized motor-
assessment and suitable for people 4 to 21 years old. Two fine motor domains (fine manual
control and manual coordination) contain four motor subtests: fine motor precision (e.g.,
cutting out a circle, connecting dots), fine motor integration(e.g., copying a star, copying
a square), manual dexterity(e.g., transferring pennies, sorting cards, stringing blocks), and
upper-limb coordination(e.g., throwing a ball at a target, catching a tossed ball). Subtest mea-
sures are available as a total point score, scale score, and age equivalent. Two fine motor
domains and fine motor composite are available as scale score, standard score, and percentile
rank. The norms of 1520 children and youth in the United States were used. The BOT-2 Test
showed good reliability and validity responsiveness for assessing motor competence in Tai-
wanese children with intellectual disabilities (Wuang & Su, 2009). Scale scores of the four
subtests were used for the analysis.
Pinch strength. Pinch-strength was measured using a hand-held pinch dynamometer in the
3-point pad pinch position. Each child was sitting in a child-sized chair without armrests, and
the childs feet were verified to be on the floor. Each childs shoulder was adducted and neu-
trally rotated, the elbow flexed at 90, the forearm in neutral position, and the wrist extended
between 0 and 30 with an ulnar deviation between 0 and 15. Three successive trials were
recorded for pinch strength. If necessary, the child took a 20-second rest break between each
strength test trial. Their maximum strength was used for the analysis. The developmental
norms for children on pinch strength have been established by occupational therapists (Bear-
Lehman, Kafko, Mah, Mosquera, & Reilly, 2002; Mathiowetz, Wiemer, & Federman, 1986):
1.043.95 kilograms at age 4; 1.724.22 kilograms at age 5; 1.814.99 kilograms at age 6.
Demographic information. The survey questionnaires asked for the following demographic
information: age, gender, height, weight, birth order, number of siblings, hand preference,
medical history, parental education level, parental employment status, and parental marital
status.

Training Activities
The training activities were 20 minutes per day for 24 consecutive weeks. The touch-screen-
tablet group was asked to do activities based on the Uncolor for iPad app (Inov 8 Educa-
tional Consulting; Montreal, Canada) and the Dexteria Jr. Fine Motor Skill Development for
Toddlers & Preschoolers app (Binary Labs Inc., San Diego, CA). Twenty four age-appropriate
applications designed for developing fine motor skills and building strength, control, and dex-
terity were selected according to their product descriptions.
The non-touch-screen-tablet group was provided typically age-appropriate fine motor
activities (e.g., using scissors, drawing, constructive play, play dough, threading and lacing)
based on the developmental frame of reference (Case-Smith & Exner, 2015). We provided var-
ious materials and tools for fine motor activities. All participating children spent the recom-
mended 20 minutes per day on their groups activities. Parents were asked to keep an activity
log of their childs daily training activities.

Procedures
Initially, every child was assessed by a registered psychologist using the PPVT-R. A reg-
istered occupational therapist administered the BOT-2 and pinch strength tests. All the
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 5

children then underwent 24 weeks of 20-minute/day training activities. Finally, these children
were reassessed by the same occupational therapist using the BOT-2 and pinch strength tests.
The occupational therapist was blinded to group membership when assessed the children.

Data Analysis
SPSS 17.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze the data, and descriptive
statistics to examine the demographic data and outcome measures for the study variables.
Differences between group demographic data were analyzed using independent t tests and
2 tests. Fishers Exact tests were used when more than 20% of the values were less than the
expected value of 5 in a contingency table.
Differences in motor performance and pinch strength between groups were analyzed using
univariate analysis tests at the pretest and posttest. A series of one-way analysis of covariance
(ANCOVA) were conducted to examine whether differences in demographic characteristics
accounted for differences in motor performance and pinch strength in the two groups. Two-
factor mixed design analysis of variance (ANOVA) was used to compare pretest and posttest
differences in the touch-screen-tablet and nontouch-screen-tablet groups. Significance was
set at p < 0.05.

Results

Training Duration
Both the touch-screen-tablet group and the non-touch-screen-tablet group participated in
about 55 hours of training activities according to their activity log. There was no significant
difference between two groups.

Fine Motor Proficiency

All 80 children had age-equivalent motor performance on the pretest and posttest. At pre-
test, there were no group differences in the four subtests BOT-2 (Table 2). At the posttest,
however, univariate analysis of each subtest indicated that the non-touch-screen-tablet group

Table . Pretest and posttest scores on the BOT- and pinch strength subtests.
Pretest Posttest
Touch-screen- Nontouch-screen- Group Touch-screen- Nontouch-screen- Group Time
tablet tablet Dierence tablet tablet Dierence Group
M SD M SD F-value M SD M SD F-value F-value

Fine motor . . . . . . . . . . .
precision
Fine motor . . . . . . . . . . .
integration
Manual . . . . . . . . . . .
dexterity
Upper limb . . . . . . . . . . .
coordination
Pinch strength . . . . . . . . . . .
(Kg)

Note. M, mean; SD, standard deviation.

p < ., p < ., p < ..
6 L. -Y. LIN ET AL.

Figure . Dierence scale score in ne motor precision.

had significantly higher scores in fine motor precision (F = 13.23, p < 0.001), fine motor
integration (F = 7.46, p = 0.008), and manual dexterity (F = 9.26, p = 0.003) than did the
touch-screen-tablet group. There was no group difference in the upper-limb coordination.
We conducted a series of ANCOVAs to examine whether differences in demographic char-
acteristic (e.g., an only child) accounted for differences in fine motor precision, fine motor
integration, and manual dexterity in the two groups. When an only child was entered as a
covariate, the observed differences in fine motor precision (F = 12.76, p = 0.001), fine motor
integration (F = 8.75, p = 0.004), and manual dexterity (F = 10.18, p = 0.002) remained
significant.
Repeated-measures ANOVA for the fine motor precision (F = 7.83, p = 0.006), fine motor
integration (F = 4.21, p = 0.044), and manual dexterity (F = 5.24, p = 0.025) subtests also
showed significant time and group interaction effects (Figures 1, 2, and 3). At post-test, perfor-
mance in fine motor precision, fine motor integration, and manual dexterity tests increased for
children in the nontouch-screen tablet group but decreased for children in the touch-screen
tablet group.

Pinch Strength
All children met the pinch strength norms. There were no pretest or posttest group differ-
ences in pinch strength. However, repeated measures ANOVA for the pinch strength showed
a significant time and group interaction effect (F = 4.45, p = 0.038; Figure 4).

Discussion
We endeavored to expand knowledge about the effects of touch-screen tablet use on fine motor
development of preschool aged children without developmental delay. Over the 24-week
training activities, children in the nontouch-screen-tablet group made significantly greater
changes in fine motor precision, fine motor integration, manual dexterity, and pinch strength
than did children in the touch-screen-tablet group. The group time interactions indicated
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 7

Figure . Dierence scale score in ne motor integration.

that post-test scores increased for children in the nontouch-screen tablet group but decreased
for children in the touch-screen tablet group. The results support the hypothesis that frequent
use of touch-screen tablet may limit development of fine motor coordination and manual dex-
terity of preschool age children (Mangen & Velay, 2010).
Gaul and Issartel (2016) reported that childrens fine motor proficiency was falling below
expected levels. They assumed that fine motor skills have been affected by environmental
factors. Screen-based activities such as using a touch-screen tablet or device have taken the
place of traditional activities such as playing with blocks, board games, construction toys,
or puzzles (Flewitt, Messer, & Kucirkova, 2015; Lauricella, Wartella, & Rideout, 2015).These

Figure . Dierence in scale score of manual dexterity.

8 L. -Y. LIN ET AL.

Figure . Dierence in pinch strength.

children may reduce the time spent engaging in traditional activities and increase the time
spent engaging in screen-based activities, resulting in a potentially detrimental effect on the
fine motor skills development. Although some occupational therapists recommend the digital
applications used in this study to support fine motor skill development, their educational and
therapeutic effects might not completely duplicate the effects of traditional non-digital age-
appropriate fine motor activities, such as using scissors, drawing, and constructive play, which
provide substantial opportunities and experience for acquiring fine motor skills.
In this study, the group x time interaction suggests that development of pinch strength may
be negatively influenced by use of a touch-screen-tablet, which supports the hypothesis that
frequently using a touch-screen tablet may limit development of muscle strength (Mangen &
Velay, 2010; Venetsanou & Kambas, 2010). The actions involved when using a touch-screen
tablet are different from those required for most peoples typical activities of daily living. For
example, when drawing in the paper based environment and the screen-based environment,
differences in childrens use of hands and fingers were observed (Price, Jewitt, & Crescenzi,
2015). Writing on a tablet surface with a plastic-tipped pen is different from writing on paper
with a ballpoint pen. Alamargot and Morin (2015) reported that writing with a plastic-tipped
pen affects the legibility and kinematics because of decreased kinesthetic feedback. A plau-
sible explanation is that children coordinated the intrinsic muscles of fingers and hands and
received abundant kinesthetic and haptic feedback about the movement when they manip-
ulated toys or objects (Case-Smith & Exner, 2015). In addition, researchers found that using
a touch-screen tablet overextended the users wrist (Mangen & Velay, 2010), which might
increase the risk for preschoolers to further develop musculoskeletal symptoms ahead of time.
These findings warrant additional research on the physiological mechanisms and function of
muscles.
The finding that more children in the touch-screen-tablet group were the only child in
the family may have implications for frequency of using a touch-screen-tablet. Increasingly,
mothers in Taiwan are undergoing higher education and working full-time and spend rela-
tively little time with their children (Westley, Choe, & Retherford, 2010). Because a family may
have only one child, certain parents may overindulge this child and tend to be less strict with
a child, allowing him or her to spend more time using touch-screen tablet. It is also reason-
able that children lived in a double-income family were more likely to engage in screen-based
activities if their parents had little time with them to engage in other activities.
Notably, many applications designed for young children were not evaluated to ensure their
adherence to safety regulations or standards. In response to the developmental and health
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 9

issues associated with screen-based activities, the American Academy of Pediatrics recom-
mends that children 2 years and older engage in no more than 2 hours of screen-based activ-
ities per day, and screen time should be limited to 20 minutes each time (American Academy
of Pediatrics, 2011).
Our findings should be cautiously interpreted because of several limitations of our study.
First, our study sample was small and participants from low socioeconomic status were not
enrolled; thus, our findings might not be generalizable to a larger population. Future research
should focus on the implications of the use of touch screen tablets for young children from a
wider community sample. Second, we did not record exactly how long our participants had
used touch-screen tablets before they were enrolled in this study. In addition, physical con-
text or type of use should be considered in the future. Third, the use of assessments has not
been standardized on the sample population. Establishing the norms of the BOT-2 and pinch
strength for Taiwanese children is required. Fourth, we did not report other aspects of devel-
opment that may be associated with the effects of touch-screen tablet use on fine motor devel-
opment, such as the development of cognitive and visual perceptual skills. Future research
using more precise assessments of these factors is required.

Conclusion
Among preschool aged children without developmental delays, fine motor precision, fine
motor integration, and manual dexterity improved more in children who did not use the
touch-screen tablet or another tablet device over the 24 weeks of training compared with
children who frequently used the touch-screen tablet or another tablet device. The findings
have implications for child-development practitioners promote the health and development
of preschool children by providing empirical knowledge about health education, appropriate
play, entertainment, and learning activities. Additional studies with larger samples are rec-
ommended to examine the effects of using a touch-screen tablet on child development over
time.

Acknowledgments
We thank all the children and family members who participated in this research.

Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing
of the article.

Funding
Support for this research was provided in part by grant MOST 103-2314-B-006-001 from the
Taiwan Ministry of Science and Technology, and in part by scholar grants from the College of Medicine,
National Cheng Kung University.
10 L. -Y. LIN ET AL.

About the Authors

Ling-Yi Lin, BSc, MSc, ScD, OT, is affiliated with National Cheng Kung University, Faculty of Occu-
pational Therapy and Allied Health Sciences, Tainan, Taiwan. Rong-Ju Cherng, BSc, MSc, PhD, PT, is
affiliated with National Cheng Kung University, Faculty of Physical Therapy and Allied Health Sciences,
Tainan, Taiwan. Yung-Jung Chen, MD, PhD, is affiliated with National Cheng Kung University, Faculty
of Medicine- Department of Pediatrics, National Cheng Kung University, Tainan, Taiwan.

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