Research in Developmental Disabilities 32 (2011) 749–756

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Impaired visuo-motor sequence learning in Developmental

Coordination Disorder
Freja Gheysen a,b,*, Hilde Van Waelvelde b, Wim Fias a
a
Department of Experimental Psychology, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium
b
Department of Rehabilitation Sciences and Physiotherapy, Ghent University, University College Arteveldehogeschool, Belgium

A R T I C L E I N F O A B S T R A C T

Article history: The defining feature of Developmental Coordination Disorder (DCD) is the marked
Received 29 October 2010 impairment in the development of motor coordination (DSM-IV-TR, American Psychiatric
Accepted 8 November 2010 Association, 2000). In the current study, we focused on one core aspect of motor
Available online 4 December 2010 coordination: learning to correctly sequence movements. We investigated the procedural,
visuo-motor sequence learning abilities of 18 children with DCD and 20 matched typically
Keywords: developing (TD) children, by means of the serial reaction time (SRT) task. Reaction time
Developmental coordination disorder measurements yielded two important findings. Overall, DCD children demonstrated
Serial reaction time task
general learning of visuo-motor task demands comparable to that of TD children but failed
Procedural sequence learning
to learn the visuo-motor sequence. Interestingly, a sequence recall test, administered after
Motor learning
the SRT task, indicated some awareness of the repeating sequence pattern. This suggests
that the sequence learning problems of DCD children might be located at the stage of
motor planning rather than sequence acquisition.
ß 2010 Elsevier Ltd. All rights reserved.

1. Introduction

Motor skills such as dressing, riding a bicycle or handwriting are essential for adequate daily functioning. Some children,
however, experience severe difficulties in acquire these skills. They perform clumsy and less coordinated than would be
expected from their age. When these motor problems cannot be explained by any medical condition, pervasive
developmental disorder or intellectual retardation and when they significantly interfere with daily life and academic
activities, this condition is labeled as Developmental Coordination Disorder (DCD) (DSM-IV-TR, American Psychiatric
Association, 2000).
Overall, children diagnosed with DCD form a heterogeneous group. They differ in the severity and the variety of their
motor and perceptual-motor problems as well as in the co-occurrence of other behavioral or learning disorders such as
ADHD, autism or dyslexia (Visser, 2003). But although the total clinical picture of children with DCD varies considerably, they
all suffer from one core problem: an impaired development of motor coordination, which forms the first and main feature for
the diagnosis of DCD (DSM-IV-TR, American Psychiatric Association, 2000).
One aspect of motor coordination entails the adequate synchronization of several movements to achieve the goal of an
action, e.g., the action of pouring water from a bottle into a glass requires one arm to reach, grasp and hold the glass while the
other arm lifts and pours the water (Weiss & Jeannerod, 1998). Such patterns of interlimb coordination have been shown to
be more variable and less stable for DCD children than for age-related peers in tasks requiring hand–hand, hand–foot and
eye–hand coordination (Volman & Geuze, 1998; Volman, Laroy, & Jongmans, 2006). Another aspect of coordination

* Corresponding author. Tel.: +32 9 264 64 03; fax: +32 9 264 64 96.
E-mail address: freja.gheysen@ugent.be (F. Gheysen).

0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2010.11.005
750 F. Gheysen et al. / Research in Developmental Disabilities 32 (2011) 749–756

necessary for adequate performance entails the execution of the correct movements over time, i.e., the correct sequencing of
movements. For instance in the aforementioned drinking action, if one pours the water first and then lifts the bottle, this
results in inadequate and clumsy behavior. In fact, sequence structure is essential for much of our everyday motor behavior:
skills such as dressing, taking the stairs, riding the bike or handwriting, all require a particular sequence of movements. It is
therefore remarkable that, although sequence learning is clearly of crucial importance for efficient motor coordination, it has
rarely been studied in the DCD population.
One exception is the study of Wilson, Maruff, & Lum (2003) that investigated the sequence learning abilities of DCD
children by means of the Serial Reaction Time (SRT) task. During the SRT task, originally developed by Nissen and Bullemer
(1987), participants have to react as fast and as accurately as possible to the location of a visual stimulus on the computer
screen by pressing the corresponding response key. The succession of the stimuli and responses follows a predetermined and
repeating sequence structure. Participants are not informed about the presence of the sequence nor instructed to learn
anything. Yet, through continued practice, they are able to acquire sequence knowledge. Such skill learning through repeated
practice is commonly recognized as ‘‘procedural learning’’. In a classical SRT design, several blocks of the repeating sequence
are presented. As decreasing reaction times over these sequence blocks can reflect both general practice effects of the visuo-
motor task as well as sequence learning effects, an additional and more reliable assessment of sequence learning is generally
implemented: the introduction of a random (test) block. If reaction time (RT) performance is significantly disrupted by this
unpredictable random sequence, it can be concluded that sequence-specific learning has occurred. Using the SRT task,
Wilson et al. (2003) concluded that the sequence learning abilities were comparable between DCD children and controls. Yet,
we claim that this conclusion must be interpreted with caution as the study used a small sample size of only 10 children in
each group and reported non-significant differences in sequence learning between groups based on a probability level of .09.
Moreover, the interpretation of the results is complicated because of methodological limitations related to the random test
block. Since this block was not matched to the sequence block in terms of sequence-independent information (i.e., the
occurrence of repetition trials and simple frequency information) and since the random block was not followed by a
sequence block, it is difficult to ensure that the RT increase in the last random block was not due to information other than
the sequence structure or fatigue.
Currently, therapy lacks consistent, evidence-based knowledge on the motor learning impairments of children with DCD.
Further research on the sequential coordination of movements and especially on the related learning process, is thus very
important, not only to have a clear understanding of the underlying causes of DCD but also to ensure optimal therapeutic
treatment. The present study therefore aimed to more thoroughly investigate the motor learning abilities of DCD children by
means of the SRT task. We are convinced that the SRT task is ideally suited for this purpose, for the following reasons.
Previous developmental research with the SRT task yielded convincing evidence that young children are able to adequately
perform the SRT task and to learn a sequence structure in a relatively short period of time (Karatekin, Marcus, & White, 2007;
Meulemans, Van der Linden, & Perruchet, 1998; Thomas & Nelson, 2001). The SRT task enables to study the visuo-motor
sequence learning abilities of DCD children as such since it induces a procedural and rather implicit form of learning, that is, a
way of sequence learning through repeated practice and without the need of conscious strategies. Furthermore, the reaction
time (RT) measurements provide an objective means to dissociate problems of general visuo-motor learning (i.e., general
information processing and motor performance inherent in task demands and independent of the presence of a sequence)
and pure sequence learning deficits. The former can be identified by computing the time course of the RT performance
relative to typically developing children; the latter by computing the RT difference between sequence and random trials,
which only differ in the presence of a repeating sequence but not in general task processes.
To ensure a reliable comparison with the previous SRT study in DCD (Wilson et al., 2003), we used identical materials,
sequence structure and amount of sequence training before testing but made some adaptations to allow firmer conclusions:
the random test block now matched the sequence blocks regarding sequence-independent information and was followed by
another sequence block to ascertain that the RT effects were attributable only to sequence specific learning.

2. Methods

2.1. Participants

The final sample consisted of 18 DCD children and 20 typically developing (TD) children. Group characteristics are shown
in Table 1.
The DCD children were recruited from schools for special education and ambulant rehabilitation centers in Flanders,
Belgium. Teachers or physiotherapists were asked to identify children who met the following criteria: children between 8
and 12 years old, having marked motor deficits interfering with daily life and academic activities, an IQ score more than 85,
no diagnosed behavioral disorder such as ADHD or autism and no medical condition interfering with their motor
development. A total of 35 children were referred to our study.
The Movement Assessment Battery for Children-Second Edition (MABC-2, Henderson, Sugden, & Barnett, 2007) was used
to assess the motor abilities of the children. The MABC is one of the most commonly used tests to evaluate the child’s general
motor functioning by assessing manual dexterity, aiming and catching, and balance. The recently translated edition in Dutch,
standardized in Flanders and the Netherlands (Smits-Engelsman, 2010), was used for the current study.
 F. Gheysen et al. / Research in Developmental Disabilities 32 (2011) 749–756 751

Table 1
Characteristic participant groups.

DCD group (n = 18) TD group (n = 20)

Age
M 10y 9y 10mo
SD 1y 1mo 1y 1mo
Range 8y 2mo–12y 6mo 8y 1mo–11y 7mo
IQ
M 102.4 107.9
SD 11.4 10.9
Range 90–129 85-124
Gender
boys/girls 14/4 12/8
% boys 77.8 60
MABC-2 percentile*
M 2.6 59.7
SD 1.8 21.1
Range 0.5–5 25–98
*
Significant differences between groups.

The short form of the Wechsler Intelligence Scale for Children-third edition (WISC-3, Grégoire, 2000) was used to assess
IQ. The short version of the WISC-3 measures the child’s intelligence on 2 verbal tests (word similarities and comprehension)
and 2 performance tests (picture arrangement and block design).
Children were included in the DCD group if their total MABC-2 score was at or below the 5th percentile (and thus having
definite motor difficulties) and if the total IQ score was at or above 85. Data were excluded from all analyses for 17 children
due to: a MABC-2 score > 5th percentile (n = 3), an IQ score < 85 (n = 10), failure to meet the exclusion criterion of ADHD
(n = 2) and failure to complete the SRT task (n = 2).
For the control group, 24 typically developing (TD) children were referred from mainstream schools. Children were
included in the TD group if they were between 8 and 12 years old, initially identified by their teachers as following typical
motor and cognitive development and if on subsequent testing their MABC-2 score was above the 16th percentile and their
total IQ score at or above 85. From the total group of 24 referrals, data from 2 children were excluded because of a MABC-2
score of percentile 16 (and thus identified as having borderline movement difficulties) and from 2 children because of an IQ
score < 85. The study was approved by the local ethical committee and written informed consent was obtained from the
parents before testing.

2.2. Serial reaction time (SRT) task

The SRT task (Nissen & Bullemer, 1987) was administered on a portable computer. Tscope software (Stevens, Lammertyn,
Verbruggen, & Vandierendonck, 2006) was used to run the experiment and to collect the behavioral data. Participants were
instructed to respond as fast and as accurately as possible to a stimulus (an asterisk), appearing at one of the four squares
horizontally organized in the middle of the screen, by pressing the corresponding key on a response box (Fig. 1). On each trial,
a black asterisk (1.5 cm  1.5 cm; 1.72  1.728 of visual angle) was presented in one of the four squares (3 cm  3 cm;
3.43  3.438 of visual angle). The squares were horizontally arranged on a white background with a small gap (3 cm, 3.438 of
visual angle) in between the squares. Responses were made by index and middle finger of both hands on four keys of a
[()TD$FIG]

Fig. 1. . The serial reaction time (SRT) task: participants were instructed to respond as fast and as accurately as possible to the location of the stimulus
(asterisk) by pressing the corresponding key on a response box.
752 F. Gheysen et al. / Research in Developmental Disabilities 32 (2011) 749–756

response box with similar horizontal mapping. As soon as a response was given or after a maximum time of 3000 ms, the
next stimulus appeared after a 250 ms interval.

2.3. Procedure

Participants were tested separately in a quiet environment and seated at approximately 50 cm in front of the computer
screen. First, they were informed about the task demands and the procedure of the experiment. They were asked to place the
index and middle finger of each hand on the four response keys and to keep the fingers on the keys during the task
performance. The experiment comprised 6 blocks of 100 trials. Rest breaks of approximately 1 min were given to the
participants in between each block. During all blocks, except for the random test block 5, the succession of the stimulus
locations (hence, responses) followed a 10 item sequence: 1, 3, 4, 2, 3, 1, 4, 2, 1, 4 which was identical as the sequence
structure used in the study of Wilson et al. (2003). This sequence was repeated 10 times in each sequence block. The
succession of the stimulus locations in the random test block 5 was randomly determined, except that repetitions of
locations could not occur and that the four locations appeared with the same frequency as in the sequence blocks: for each
subset of 10 trials, locations 1 and 4 occurred three times, locations 2 and 3 occurred twice. This constraint ascertained that
learning effects were attributable to the sequence structure only and not to simple frequency information.

2.4. Sequence awareness tests

After completing the SRT task, participants were tested on their explicit awareness of the sequence to determine whether
the extent of sequence awareness had an impact on sequence learning abilities. First, they were asked the following
question: ‘‘Were you able to tell where the next asterisk was going to be next, i.e., could you ever predict which response to
press even without having seen the next asterisk?’’ Next, they were informed about the presence of a repeating sequence and
asked to recall that sequence by marking a series of displays of the four squares on a sheet of paper. Participants were first
told to produce a sequence that resembled the trained sequence as much as possible (free recall under inclusion condition).
Then, they were instructed to produce another sequence that differed as much as possible from the trained sequence (free
recall under exclusion condition). In both conditions, they were instructed to avoid repetitions and to fill in all the displays
for 22 trials long. The proportion of triplets consistent with the sequence, under inclusion and exclusion instructions, was
computed. As such, the amount of sequence awareness can be obtained by computing the difference between performance
under inclusion and exclusion instructions. Participants having a high inclusion score (i.e., that are able to correctly recall the
trained sequence) and a low exclusion score (i.e., that are able to refrain from that sequence by generating a different one) are
suggested to have some conscious awareness of the sequence (Destrebecqz & Cleeremans, 2001).

3. Results

3.1. General assessment

Age, IQ, gender and MABC-2 data (Table 1) were compared between the DCD group and the TD group. MABC-2 scores
differed significantly (t(19.32) = 12.08, p < .001) between groups but no difference in age (t(36) = .55, p = .59), IQ (t(36) = 1.54,
p = .13) and gender (x2(1) = 1.39, p = .24) was found. The two groups thus clearly differed in their motor abilities but were
matched for age, IQ and gender.

3.2. Accuracy

The mean rate of erroneous responses was 5.65% (SD = 2.15) for the DCD group and 3.94% (SD = 2.50) for the control group.
The overall difference between groups was significant, t(36) = 2.25, p < .05, but as these error rates are too low to draw
meaningful conclusions, they were not analyzed further.

3.3. Reaction time (RT) measurements

For RT analyses, incorrect responses and trials following incorrect responses were removed. Next, for each participant,
median RTs were computed for each block and used for further analyses.

3.3.1. General practice effects

A repeated measures ANOVA with the first 4 sequence blocks (i.e., the blocks preceding the random test block) as within-
subjects factor and group as between-subjects factor was carried out to determine general effects of task practice. A
significant effect of group was found (F(1,36) = 9.12, p < .01) indicating overall slower responding for the DCD group
compared to the TD group (Fig. 2). The main effect of block was significant (F(3,108) = 38.62, p < .001) but interestingly, no
significant interaction between block and group was found (F(3,108) = 1.12, p < .35) and linear trend analysis indicated no
difference in overall RT decrease between groups (F(1,36) = 1.06, p = .31). Altogether, the above results indicate that,
although DCD children responded overall more slowly than TD children, they demonstrated comparable task practice effects.
[()TD$FIG] F. Gheysen et al. / Research in Developmental Disabilities 32 (2011) 749–756 753

Fig. 2. . Mean of the median reaction times in each block for the DCD and the TD group, error bars represent the within subject 95% confidence intervals.

3.3.2. Sequence learning effects

A repeated measures ANOVA with blocks 4, 5 and 6 as within-subjects factor and group as between-subjects factor was
performed to assess sequence specific learning. Again, a significant main effect of group (F(1,36) = 7.42, p < .01) and block
(F(2,72) = 22.59, p < .001) was found. But now, also the interaction between block and group was found to be significant
(F(2,72) = 9.21, p < .001). Planned comparisons contrasting the RTs on the random block 5 against the RTs on the two
surrounding sequence blocks 4 and 6 indicated no significant sequence learning for the DCD group: the difference between
random block 5 and the surrounding sequence blocks was not significant, F(1,36) = 1.08, p = .30. On the other hand, the TD
group did show a clear sequence learning pattern with a significant difference between the random block and the
surrounding sequence blocks, F(1,36) = 40.91, p < .001.

3.4. Sequence awareness

On the first question, asking the children whether they could tell where the next stimulus was going to be, 5 out of the 18
DCD children and 5 out of the 20 control children answered ‘‘yes’’. However, it must be noted that this group of children did
not perform better on the subsequent recall test compared to the group of children who answered ‘‘no’’ on this question.
On the next test, children were informed about the presence of a repeating sequence and asked to reproduce the sequence
for 22 trials long (inclusion) and subsequently, to generate a sequence different from the trained sequence for 22 trials long
(exclusion). The proportion of triplets consistent with the sequence under inclusion and exclusion instructions was
computed for both groups (Fig. 3) together with the difference score (proportion inclusion minus proportion exclusion).
For the DCD group, a significant difference was observed between recall under inclusion (M = .42, SD = .17) and exclusion
conditions (M = .23, SD = .18): t(17) = 2.96, p < .01. The inclusion scores also differed from chance level, t(17) = 3.38, p < .01,
[()TD$FIG]whereas the exclusion scores did not, t(17) = 1.18, p = .25. Chance level was set on .28 (i.e., with 4 locations, 36 triplets

Fig. 3. . Results recall test: mean proportion of sequence consistent triplets, under inclusion and exclusion conditions for the DCD and the TD group, error
bars represent the within subject 95% confidence intervals.
754 F. Gheysen et al. / Research in Developmental Disabilities 32 (2011) 749–756

without repetition of locations can be generated; 10 of these triplets belonged to the sequence therefore chance performance
is 10/36). Similar results were obtained in the TD group: recall under inclusion (M = .50, SD = .26) significantly differed from
recall under exclusion conditions (M = .33, SD = .21): t(19) = 2.14, p < .05. The inclusion scores differed from chance level,
t(19) = 3.73, p < .01, whereas the exclusion scores did not, t(19) = 1.15, p = .27. These results suggest that both groups of
children had some awareness of the presence of a repeating sequence. But importantly, the amount of awareness (i.e., the
difference scores) did not differ between groups, t(36) = .26, p = .80.

4. Discussion

Results from the current study indicated two important findings. General learning of the visuo-motor task demands was
found to be comparable between the DCD and the TD children. Sequence specific learning, however, differed between both
groups: overall, the group of TD children showed a reliable sequence learning pattern whereas the group of DCD children
failed to learn the visuo-motor sequence.

4.1. General visuo-motor task learning

SRT task performance entails rather simple task demands. No complex simultaneous coordination between limbs is
required; yet, optimal performance requires sustained attention to the task and several processes to function normally such
as visuospatial processing, stimulus-response mapping and motor selection/execution. In the present study, DCD children
were able to adequately perform the SRT task. They showed high levels of accuracy (cf Thomas & Nelson, 2001) and although
DCD children responded more slowly than TD children, general practice effects were comparable to that of the TD children.
Overall, DCD children displayed a similar decrease in RT performance, meaning that the visuo-motor processes composing a
single trial were learned at a comparable rate. This finding is important in light of the numerous DCD studies showing deficits
on almost all measures of information processing (for a review, see Wilson & McKenzie, 1998).

4.2. Visuo-motor sequence learning

Current results yielded a significant difference between the DCD group and the TD group regarding sequence specific
learning: overall, the TD group demonstrated clear evidence of sequence learning whereas the DCD group did not. As
sequence learning was measured by comparing the RTs of sequence trials to the RTs of random trials, and as sequence and
random trials only differed in the presence of a repeating sequence structure, the differential sequence learning effects
between groups could not have been confounded by general difficulties in motor task performance. Our study thus provided
evidence of a learning impairment in children with DCD specific to the sequential aspects. These findings are in line with the
core problems of these children in learning daily motor skills which are typically composed of a specific coordination of
movement sequences. The results are also compatible with the developmental Motor learning disability (MLD) hypothesis
suggesting that the motor problems of DCD children can be conceptualized as common difficulties in motor learning
(Ahonen, Kooistra, Viholainen, & Cantell, 2004; Hands & Larkin, 2001). Yet, the current study complements this hypothesis
by specifying the motor learning problems: overall, the children with DCD in our study had no problems with general visuo-
motor learning but were specifically impaired on sequence learning.
Our conclusions are not consistent with the previous study investigating procedural visuo-motor sequence learning in
children with DCD (Wilson et al., 2003). Wilson and colleagues reported no significant differences between DCD and control
children in sequence learning although an identical SRT task, sequence structure and amount of sequence repetitions before
testing (i.e., before introducing the random test block) were used. They claimed that the negative slope of the mean RTs over
the first four sequence blocks in DCD children strongly suggested evidence for learning the repeated sequence. Yet, this
reduction in RT performance can also reflect general task practice. In fact, this is clearly demonstrated in our study: the DCD
group demonstrated similar RT decreases over blocks as the TD group, but no sequence specific learning. Furthermore, in
Wilson’s study, the so-called rebound effect (i.e., the RT interference on the random test block which represents a much more
reliable test for sequence specific learning) was reported not to differ between DCD and control children. Yet again, this
conclusion was not convincing as they reported a probability of .09 for this difference in a sample of 10 DCD and 10 TD
children. The difference in results between our study and the study of Wilson et al. (2003) is therefore less contradictory than
it might seem at first sight. Nonetheless, we suggest that three main factors might be at the origin of these seemingly
contradictory results. First of all, differences in group selections could have influenced results. In the current study, we only
included children with definite motor problems in the DCD group (inclusion criterion: MABC-2  5th percentile), whereas
Wilson and colleagues included children with borderline motor problems as well (inclusion criterion: MABC  15th
percentile). But also methodological factors might have contributed to the differential results. In the study of Wilson and
colleagues, the random test block was not matched to the sequence blocks in terms of simple frequency information. The
sequence structure used in Wilson’s study contains specific frequency information, in that location 1 and 4 occur three times
and location 2 and 3 occur twice for every 10 trials. Shanks, Green, and Kolodny (1994) convincingly demonstrated that if
such frequency information is not matched in the random test block, the acquisition of frequency information alone can
account for learning in SRT tasks. Consequently, it might be that the RT increase in the random test block in Wilson’s study
reflected learning of simple frequency information rather than sequence specific information. Moreover, since this random
 F. Gheysen et al. / Research in Developmental Disabilities 32 (2011) 749–756 755

block was not followed by a sequence block, the RT increases in this last block of the experiment might have been influenced
by general effects of fatigue or reduced motivation.

4.3. Implications for the potential neuropathology of DCD

From a neuroscience perspective, the observed sequence learning problems in the DCD group might reflect neural
dysfunctions of the striatum. Previous research indicated a prime function for the striatum in procedural sequence learning
(Destrebecqz et al., 2005; Peigneux et al., 2000; Rauch et al., 1997). The assumption that the striatum, and the basal ganglia
more in general, could be implicated in the neuropathology of DCD has been suggested previously in the context of motor
control (Groenewegen, 2003; Lundy-Ekman, Ivry, Keele, & Woollacott, 1991; Querne et al., 2008). But also other neural
structures such as the hippocampus (Gheysen, Van Opstal, Roggeman, Van Waelvelde, & Fias, 2010) and the cerebellum
(Doyon et al., 2009) have been proposed to contribute to the process of learning new motor sequences. The fact that the
cerebellum could be involved in the neuropathology of DCD has been frequently proposed given its function in motor
coordination and adaptation, postural control and timing, problems characterizing the DCD population (Gramsbergen, 2003;
Ivry, 2003; Zwicker, Missiuna, & Boyd, 2009). In addition, cerebellar dysfunctions in DCD have been hypothesized since
structural and functional abnormalities have been frequently reported in comorbid disorders such as dyslexia, ADHD and
autism (e.g., Acosta & Pearl, 2004; Nicolson et al., 1999; Seidman, Valera, & Makris, 2005). However, direct (imaging)
measures are needed to further investigate the potential involvement of neural regions such as the basal ganglia,
hippocampus or cerebellum in the etiology of DCD.

4.4. Further considerations and future research

Learning sequence information is crucial for daily functioning because it enables efficient and fluent behavior. That is,
based on the sequence knowledge, one can adequately predict the upcoming event and actions can be planned in a
feedforward manner. The fact that overall, the DCD group was not able to learn the sequence, might contribute to the clumsy
behavior observed in these children. The sequence recall task provided further interesting results in this regard. Both the TD
and DCD group appeared to have some awareness of the repeating sequence which did not differ between groups. This
suggests that the sequence learning differences observed between groups (based on RT performance) were not influenced by
the amount of awareness. Interestingly though, the DCD children (in contrast to the TD children) did not seem to use this
sequence knowledge to refine their actions. This might suggest that the problems of DCD children were not located at the
sequence processing/acquisition stage of the learning process but rather at the level of motor preparation/planning. Similar
conclusions were drawn from previous studies using visual pointing paradigms (Wilmut & Wann, 2008; Wilmut, Wann, &
Brown, 2006). In these studies, the DCD group performed equally well as controls on simple pointing to visual targets, yet, did
not always make effective use of advance visual information to prepare accurate responses. Overall it seems that, even when
predictive information is available informing them where the next target will appear, children with DCD continue to use a
look-then-move strategy rather than to control their movements in a feedforward manner.
Although the current study provided several interesting and new insights in the problems facing DCD children, additional
research is necessary to elaborate these findings. Tracking sequence learning over several sessions and over large samples of
children could explore to what extent DCD children can profit from additional sequence training and elucidate whether this
procedural sequence learning deficit is common among the DCD population. Furthermore, it would be very interesting to
compare procedural, implicit forms of sequence learning, i.e., learning through repeated practice, without intentional and
conscious control (as in the current study) versus explicit forms of sequence learning, i.e., intentional learning, receiving
verbal instructions and prior conscious knowledge of the sequence. This manipulation could provide very interesting
information for the clinical practice in defining which learning strategy to employ in the rehabilitation of DCD children.

Acknowledgements

This work was supported by the Ghent University Multidisciplinary Research Partnership ‘‘The integrative neuroscience
of behavioral control’’ and by Grant P6/29 from Interuniversitary Attraction Poles program of the Belgian federal
government. The first author was supported by a grant from the Research Council of Ghent University. We are thankful to all
the teachers, therapists and children for their participation in this study. We also wish to thank Julie Debrabant, Tinneke
Hellinckx and Stefanie Pieters for their assistance in the recruitment.

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