Soft Neurological Sign Profile in 7 and 8 Years Old Children In Three Primary Shools in

Bandung City, Indonesia

Dessy1,2), Siti Aminah1,2), Lisda Amalia1,2)

1)
Department of Neurology Hasan Sadikin Hospital, Bandung, Indonesia
2)
Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia

[Introduction] Soft Neurological Sign (SNS) is known to be correlated with learning disabilities, and in children
may help to detect learning disabilities earlier. The worldwide prevalence is about 10% in school-age children, but in
Indonesia is still unknown. This study was to discover SNS examination profile in 7 and 8 years old children and to know
the differences within gender and age.
[Methodology] Analytic descriptive cross sectional study was used, with Gillbergs method, consist of 20 items
(score 0-40). Normal score was less than mean 1SD, high score if more than mean 1SD. The study examine children age
7 and 8 years old in Primary School Sekejati, Sukajadi 3, and Pasirkaliki 139 Bandung, from April to June 2016, with
exclusion criteria abnormal hard neurological sign. Data then analyzed by T and Chi-square test.
[Results] 259 children were included in this study, among them 48.6% were boys, 51.4% were girls. In this
population SNS score is high if 7 (Mean 3.7, SD 2.6 = 6.3). 14.3% children with high SNS score. There were 20.6% of
boys and 8.3% of girls were observed with high SNS score, statistically significant (p=0.001, CI 95%, and OR=2.884).
From the age group, 18.4% of aged 7 and 10.4% of aged 8 with high SNS score, also statistically significant (p=0.004, CI
95%, and OR=1.933).
[Conclusions]. In this study SNS score was high if the score 7. There were 14.3% children with high SNS score
from this study, with statistically significant differences based on gender and age.
Keywords: Age, Gender, Gillberg, Soft neurological sign.

Introduction
Maturity of childs motor system is affected by many factors such as environment stimulation and opportunity to make
movement. The active game is important factor that benefit to physical development, cognition, social, language, and
emotion of children. 1,2. In this modern era, with high urbanization, city life style, and development in technology, the
pattern of game in children has changed. Child is more affected by television and play video game than play in open
environment, therefore interaction with environment and opportunity to make movement become limited. The changing of
play pattern cause child become at risk to get motor skills development disorder. 3,4
Some researchers have found some children that have difficulty to do skills motor movement such as coordination, less
speed or extremity accuracy, and balance disorder, but in conventional neurological examination, there were no abnormality.
This things then is called as soft neurological sign. 5-8
Soft neurological signs are minor, non localizing, objective abnormalities, which include poor motor coordination,
sensory perceptual difficulties and difficulties in sequencing of complex motor tasks, result from specific or diffuse brain
structural abnormalities. 9-12 They thought to reflect damage in cortical and sub-cortical connections or connections within
different cortical regions. 9,11,13
In Martins study, the highest incidence of soft neurological sign was before puberty and then diminished on age 11-17
years old. 8 Soft neurological sign is related to some nervous system development disorder such as low IQ, autism, learning
disabilities, dyslexia, and hyperkinetic disorder. 8,13,15-17
Soft neurological signs examination may be useful for identification predispotition to hyperkinetic disorder, learning
disabilities, for estimating prognosis, and monitoring response to therapy. 8,17 Early detection needed so that intervention
can be held faster for prevent pathologic development. 13
The prevalence of soft neurological sign is about 10% in school aged children but in Indonesia there is still unknown.
The age of formal education in Indonesia start from 7 years old. Author examined children aged 7 and 8 years old. 6 years
children still perform transient regression in postural response control, while in children of 7-8 years old have more stable
when they walk in narrow road. 20,21. In age 9, most motor functions and praxis had matured. 22 Study done by
Schoemaker in Holland in 2012 showed that prevalence of high soft neurological sign score in 7 years old children was
15.3% and in 8 years old children was 7.3%. 20
The author use Gillbergs method because the duration of the examination is short, no need expensive tools, easy to done,
have reliability 91-95%, sensitivity 80%, and specificity 76%. 7,23

Aim
The aim of this study was to discover SNS examination profile in 7 and 8 years old children and to know if there was
differences within gender and age.

Method
The study examine children age 7 and 8 years old in 3 Primary School in Bandung city : Sekejati, Sukajadi 3, and Pasirkaliki
139 Bandung, from April to June 2016. Number of sample was 259 children. This was cross sectional study. Inclusion
criteria was children aged 7-8 years old, and their parents were willing to contribute in this study. Exclusion criteria was
children with history of cerebral palsy, meningitis, brain tumour, not cooperative, and have abnormality in hard
neurological signs examination. We did interview, hard neurological sign examination, and soft neurological sign
examination using Gillbergs method.

Table 1. Gillbergs soft neurological sign examination

1. Diadochokinesis, right and left : 0-2 respectively
0= more than 10 alternating hand movement in 10s with smooth movements and deviation of arm from body less
than 5 cm
1= Jerky movements or deviation of arm from body >5 cm but <15 cm
2= Fewer than 10 alternating hand movements in 10s or deviation of arm >15 cm
2. Standing on right and left leg: 0-2 respectively
0= Managing longer than 60s
1= longer than 10s but with difficulty, unsteadiness
2= Managing less than 10s or more than one interruption
3. Hopping on right and left leg : 0-2 respectively
0= Hopping 20 times on the same place, less than 12s
1= Big movements of arms and body or one interruption
2= More than one interruption, very jerky movements, not managing to remain in the same place or not being able
to lift foot entirely from the floor
4. Prechtl: standing with arms forward with palms of the hands downwards for 20s with eyes closed and tongue
protruding from mouth.
(a) Choreatic movements (rapid involuntary movements) right and left hand: 0-2 respectively
(b) Athetotic movements (slow involuntary movements) right and left hand: 0-2 respectively
(c) Spooning (hyperextension of metacarpo-phalangeal joints and flesion of wrist) right and left hand: 0-2
respectively
(d) Tremor right and left hand: 0-2 respectively
5. Walking on heels: 0-2
0= No problems
1= More than small symmetric movements of arms or asymmetric arm position
2= Flexion of elbow greater than 60 degree or abduction and movements of lips and tongue
6. Fog test (walking on lateral border of feet): 0-2
0= No problems
1= More than small symmetric movements of arms or asymmetric arm position
2= Flexion of elbow greater than 60 degree or abduction and movements of lips and tongue
7. Bishops test (tracking with a pencil between two quadrates, one inside the other, done with both hands
simultaneously): 0-2
0= Fewer than five line crossings on paper (drawing on area between the two squares)
1= More than five line crossings on at least one side but difference between left and right 6
2=Difference between number of line-crossings for left and right hand greater than 6

8. Alternating jumps with one leg forward the first jump, and then the other, ets: 0-2
0= Jumps 20 times on the same place, less than 12s
1= one interruption
2= More than one interruption, not managing to remain in the same place or not being able to lift foot entirely from
the floor
9. Alternating crossed jumps, with one arm thrown forward the same time as the contra lateral leg is thrown forward,
and then the opposite arm and contra-lateral leg are thrown forward, etc: 0-2
0= Jumps 20 times on the same place, less than 12s
1= one interruption
2= More than one interruption, not managing to remain in the same place or not being able to lift foot entirely from
 the floor
10. Finger opposition: the thumb is opposed to one at the time of the other fingers, left and right scored together: 0-2
0= No problems
1= Mirror movement
2= unable

Total score is said normal if the score less than mean + 1 SD and score is high if more than mean + 1 SD.7 Analysis used T
test and Chi-square test.

Result
From 259 subjects, 47 children from Sekejati Primary School, 90 children from Sukajadi 3 Primary School, and 122
children from Pasirkaliki 139 Primary School. Subjects aged 7 was 48.5% (125 children) and aged 8 was 51.7% (134
children). Male was 48.6% (126 children) and female was 41.4% (133 children). Most of their parents education level was
senior high school (64.1%). Average economic class of parents was on lower economic level (57.1%).

Table 2. Subjects Characteristic

Variable N=259

Age
7 years old 125 (48.3%)
8 years old 134 (51.7%)

Gender
Male 126 (48.6%)
Female 133 (51.4%)

Fathers education
Primary School 28 (10.8%)
Junior High School 44 (17.0%)
Senior High School 166 (64.1%)
Others 21 (8.1%)

Mothers education
Primary School 22 (8.5%)
Junior High School 55 (21.2%)
Senior High School 148 (57.1%)
Others 34 (13.1%)

Parents income 148 (57.1%)

<2.5 million (low) 96 (37.1%)
2.5-5 million (moderate) 15 (5.8%)
> 5 million (high)

Soft neurological sign examination by Gillberg has 20 items

Table 3. Results of Soft Neurological Sign examination per item

SCORE (N=259)
Variable
0 1 2
Right diadochokinesis 232 (89.6%) 27 (10.4%) 0 (0%)
Left diadochokinesis 233 (90%) 26 (10.0%) 0 (0%)
Standing on right leg 187 (72.2%) 62 (23.9%) 10 (3.9%)
Standing on left leg 178 (68.7%) 65 (25.1%) 16 (6.2%)
Hopping on right leg 198 (76.4%) 61 (23.6%) 0 (0%)
Hopping on left leg 198 (76.4%) 58 (22.4%) 16 (6.2%)
Right choreatic movement 259 (100%) 0 (0%) 0 (0%)
Left choreatic movement 259 (100%) 0 (0%) 0 (0%)
Right athetotic movement 259 (100%) 0 (0%) 0 (0%)
Left athetotic movement 259 (100%) 0 (0%) 0 (0%)
Right arm spooning 256 (98.8%) 3 (1.2%) 0 (0%)
Left arm spooning 256 (98.8%) 3 (1.2%) 0 (0%)
Right hand tremor 258 (99.6%) 1 (0.4%) 0 (0%)
Left hand tremor 259 (100%) 0 (0%) 0 (0%)
Walking on heels 224 (86.5%) 32 (12.3%) 3 (1.2%)
Fog test 163 (62.9%) 89 (34.4%) 7 (2.7%)
Bishops test 153 (59.1%) 92 (35.5%) 14 (5.4%)
Alternating jumps 228 (88.0%) 29 (11.2%) 2 (0.8%)
Cross jumps 98 (37.8%) 125 (48.3%) 36 (13.9%)
Finger opposition 169 (65.3%) 79 (30.5%) 11 (4.2%)

Each item on this examination is scored as 0,1, or 2. The smaller the score the better it was.
On table 2 we can see that score 2 most found on cross jump item (13.9%), as score 0 in this item only 37.8%. It showed that
cross jumps was the most difficult item to do for children aged 7 and 8 years. Score 2 in item standing on left leg was 6.2%,
and Bishops test 5.4%. For involuntary movement (choreatic, athetotic, spooning, and tremor), most of the children get
good score. All score in each item then compute to be total score.

Table 4. Total Score of Soft Neurological Sign Examination with Gillbergs method in children aged 7 and 8

Variable N=259
7 years old
Mean 4.18
Median 4
Standard Deviation 2.656
Range 0-14

8 years old
Mean 3.23
Median 3
Standard Deviation 2.630
Range 0-14

Boys
Mean 4.29
Median 4
Standard Deviation 3.056
Range 0-14

Girls
Mean 3.13
Median 3
Standard Deviation 2.13
Range 0-10

All subjects
Mean 3.67
Median 3
Standard Deviation 2.647
Range 0-14

From Table 4 we can see that total score of SNS examination with Gillbergs method in 7 and 8 aged years children was
range from 0 to 14, with mean was 3.67 and median was 3. For 7 years old children, mean of total score was 4.18 and for 8
years old children was 3.23. Mean total score for boys was 4.29, and for girls was 3.13.
The next step is to determine wether the score is normal or high. Based on previous study using same method, score
was high if the score more than mean + 1SD. In this study, we get the mean was 3.67 with standard deviation was 2.647. In
this study mean + 1 SD was 3.67+2.647 = 6.317. So that score 7 was high score. From 259 subjects, there were 37 (14.3%)
children with score 7. Relation of gender and soft neurological sign was test with T test.

Table 5. Soft Neurological Sign Examination Based on Gender

Gender N Mean score Standar Deviation Different mean P value
Boys 126 4.29 3.056
1.158 0.001**
Girls 133 3.13 2.130

Table 5 show differences in result SNS examination based on gender, highly significant (p<0.01). Boys tend to have higher
score than girls.
Table 6. Soft Neurological Sign Examination Based on Age
Age N Mean score Standar Deviation Different mean P value
7 125 4.18 2.656
0.953 0.004*
8 134 3.23 2.630

Table 6 shows the highly significance differences of SNS score between children aged 7 and children aged 8 (p<0.01).
Children aged 7 years old tend to have higher score than children aged 8 years.
To know how was the ratio to get high score of SNS based on gender and age, we calculate odds ratio by Chi-square
analysis.

Table 7. Interpretation of Soft Neurological Sign Examination

Interpretation of SNS Examination Total Odds Ratio (95% P value
Variable High Normal Confidence
Interval
Gender
Boys 26 (20.6%) 100 (79.4%) 126 (100%) 2.884 0.004**
Girls 11 (8.3%) 122 (91.7%) 133 (100%) (1.358-6.122)

Age
7 years 23 (18.4%) 102 (81.6%) 125 (100%) 1.933 0.049*
8 years 14 (10.4%) 120 (89.6%) 134 (100%) (0.946-3.951)

All 37 (14.3%) 222 (85.7%) 259 (100%)

Table 7 shows that from 259 subjects, there were 37 subjects (14.3%) with high SNS score (7). Boys have more risk to
have high SNS score than girls (2.884 times). There were 20.6% boys with high score and 8.3% girls with high score.
Children aged 7 years have more risk to have high SNS sore than children aged 8 years (1.933 times). There were 18.4%
children aged 7 with high score and 10.4% children aged 8 years with high score.

Discussion

In this study, most of subjects parents have education till senior high school and from lower economy class. Parent with
high education tend to think that play is essential part of childs life. Parent support their children to play and they have time
also to join with their children. Poverty and urban living resulting in stressed parenting and lack of access to natural and
outdoor environments, can lead to relative play deprivation.4
In this study we found that in children with normal and high score there were tend to have immaturity more on lower
extremities. The examination of this lower extremity is related to balance and postural control.20 Motor skills develop from
cephalic to caudal.22 Brain stem motor system had developed since born but corticospinal system had not fully developed.
Maturity of this system is triggered by neural activity and movement experience.23 After birth, infant learn to cope with
gravity and the continual flux of physical growth. Experience is the critical factor for promoting adaptive responding to
changes in body dimensions and variations in the environment. In the beginning, exploration of objects is restricted to the
things within arms reach. After the onset of mobility, infants are less dependent on their caregivers for making contact with
the environment. Then they begin to perceive the surface layout and learn to control balance and adjust body posture. 24
Number of subjects in this study was 259 children aged 7 and 8 years, consist of 51.4% girls and 48.6% boys. Mean SNS
score for boys was 4.29 3.0566 and for girls was 3.13 2.13. Boys aged 7 and 8 years with high SNS score was 20.6% and
for girls was 8.3%. Boys have risk 2.884 times more than girls to have high SNS score.
With increase of age, resolution of soft neurological sign is faster in girls than boys.8,17 Martins study (Portugis, 2008)
found that females reach the lowest scores two years before the younger subgroup of males. Females were better in speed of
information processing, psychomotor speed, and made fewer errors on a test of cognitive flexibility while males were better
at visual memory, visuospatial tasks and motor speed. The sex effects observed in SNS suggest a different maturation of
fine motor abilities between males and females,more precisely a delayed maturation in males, since scores become identical
by age 15 to 17 years.6,8
Seven years old subjects were 48.3% and 8 years old subjects were 51.7%. Mean SNS score in children aged 7 was 4.18
2.656, and for children aged 8 was 3.23 2.630. Children aged 7 having high SNS score was 18.4% and aged 8 was 10.4%.
From analysis, we found that children aged 7 was had risk 1.933 times to have high SNS score than children aged 8.
The behavioral findings in the current study are consistent with previous studies using the PANESS (cole, 2008), where
speed of responding improves with age, and overflow (co-movement of body parts not specifically needed to efficiently
complete a task), and dysrythmia diminish over time in typically developing children.6 Investigators have demonstrated
that transcallosal inhibition is absent in children under 6 years of age and that it gradually matures to adult levels by early
adolescence. When intra- and inter- cortical inhibitory and excitatory systems are mature, overflow movements are more
difficult to elicit.15,18
For children aged 7 and 8 years group, result of this study found the same result as Gillbergs study 14.3%, but mean + 1
SD in this study is different. In this study, child having high SNS score if the score 7, in Gillbergs study high SNS score
is if the score 5. 7
 Schoemakers study in 2012 at Holland using MABC tools found soft neurological sign in 7 years old children was
15.3% and in 8 years old children was 7.3%. This was fewer than the result of this study. The differences result of SNS in
Bandung city and in other country may be caused by many factors, such as genetic, differences of ethnic, environment,
nutritional status, exploration, and playing pattern. Chow in 2001 studied soft neurological sign in American children and
Chinese children in Hongkong used MABC. He found that American children was better in catching moving objects like
ball. This is may be cause different experience when they were at preschool. In Hong Kong, most children live in tower
blocks in urban areas, and outdoor play is extremely limited. In contrast, in the United States, outdoor play is part of life.27
Buchanan and Heinrichs also found that African American people have higher SNS score than Caucasian. 8

Conclusion
In this study SNS score was high if the score 7. There were 14.3% children with high SNS score, with statictically
significant differences based on gender and age.

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