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Exploring the Link between Visual Perception, Visual-Motor Integration, and

Reading in Normal Developing and Impaired Children using DTVP-2

Article in Dyslexia · April 2017

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 DYSLEXIA
Published online in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/dys.1561

■ Exploring the Link between Visual

Perception, Visual–Motor Integration,
and Reading in Normal Developing and
Impaired Children using DTVP-2
Stéphanie Bellocchi1* , Mathilde Muneaux2, Andréa Huau3,
Yohana Lévêque2,4, Marianne Jover3 and Stéphanie Ducrot2
1
University Paul-Valéry Montpellier, Epsylon Research Unit EA 4556, Montpellier, France
2
Aix Marseille Univ, CNRS, LPL, Aix-en-Provence, France
3
Aix Marseille Univ, PSYCLE, Aix-en-Provence, France
4
Lyon 1 University, Lyon Neuroscience Research Center (CRNL), Lyon, France

Reading is known to be primarily a linguistic task. However, to successfully decode written

words, children also need to develop good visual-perception skills. Furthermore, motor
skills are implicated in letter recognition and reading acquisition. Three studies have been
designed to determine the link between reading, visual perception, and visual–motor
integration using the Developmental Test of Visual Perception version 2 (DTVP-2). Study
1 tests how visual perception and visual–motor integration in kindergarten predict reading
outcomes in Grade 1, in typical developing children. Study 2 is aimed at finding out if these
skills can be seen as clinical markers in dyslexic children (DD). Study 3 determines if
visual–motor integration and motor-reduced visual perception can distinguish DD children
according to whether they exhibit or not developmental coordination disorder (DCD).
Results showed that phonological awareness and visual–motor integration predicted reading
outcomes one year later. DTVP-2 demonstrated similarities and differences in visual–motor
integration and motor-reduced visual perception between children with DD, DCD, and
both of these deficits. DTVP-2 is a suitable tool to investigate links between visual
perception, visual–motor integration and reading, and to differentiate cognitive profiles of
children with developmental disabilities (i.e. DD, DCD, and comorbid children). Copyright
© 2017 John Wiley & Sons, Ltd.

Keywords: reading; visual perception; developmental dyslexia; developmental-coordination disorder;

comorbidity

INTRODUCTION

Academic success is usually based on the ability to read proficiently. Reading is

essential for learning academic subjects and developing new cognitive skills.
Consequently, there is a great deal of interest in the skills that affect reading ability
and contribute to its improvement. Studying both the development of normal or

*Correspondence to: Stéphanie Bellocchi, University Paul-Valéry Montpellier, Epsylon Research Unit EA 4556,
Montpellier, France. E-mail stephanie.bellocchi@univ-montp3.fr

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

 S. Bellocchi et al.

impaired reading abilities and its predictors would help in developing teaching or
remedial methods and identifying children at risk for later reading difficulty. The
purpose of this paper was to evaluate the link between reading, visual perception,
and visual–motor integration using a pre-existing battery to test these skills
(Developmental Test of Visual Perception version 2 (DTVP-2), Hammill, Pearson,
& Voress, 1993).

Phonological Awareness and Reading: A Well-Established Fact

The fact that speech abilities, especially phonological awareness, assist reading
acquisition is now well known, both in the scientific literature and in childcare
centres. Phonological awareness refers to the ability to detect and manipulate
individual speech sounds (Goswami & Bryant, 1990). It has been argued that,
because letters usually represent individual phonemes in alphabetic languages, a
child needs to be aware of the phonemic segments in spoken words before going
on to learn about their correspondences with letters or group of letters (Gough &
Hillinger, 1980). This ability would influence reading acquisition (Torgesen,
Wagner, & Rashotte, 1994) and could even predict word-reading development
(Kirby, Desrochers, Roth, & Lai, 2008). Some studies have established a
relationship between a deficit in phonological awareness and difficulties in children
with specific reading impairment such as developmental dyslexia (DD) (Goswami
& Bryant, 1990; Vellutino, Fletcher, Snowling, & Scanlon, 2004). Developmental
dyslexia is defined as a specific disability in learning to read and spell, in spite of
normal intelligence, adequate instruction, socio-cultural opportunity, and no
sensory defects in vision or hearing (WHO, 1992). The huge body of research
on normal and impaired readers has provided numerous reliable tests or remedial
intervention programs based on phonological awareness. However, beyond this
well-documented relationship between phonological skills and learning to read,
one should not ignore that there is much more to reading than phonological
awareness.

Visual Processing and Reading: An Important Issue to Consider

Even if it is well known that to learn to read, children must develop good linguistic
skills, reading also requires a visual analysis of a uniquely ordered array of letters
such as a familiar word and retrieval of the word representation from memory.
The idea of the implication of visual skills in reading is not a recent one (Morgan,
1896), but it still remains an infrequently investigated issue. Recently, Franceschini
et al. (2012) showed that visual–spatial attention in preschoolers is an important
predictor of reading development. Children who had poor reading abilities during
the first or second year of reading education made significantly more errors on a
visual-search task and a spatial-cueing task than normal readers had when they
were in kindergarten. Moreover, several studies tend to show that a number of
dyslexics present a visual-processing deficit independently of phonological skills
(e.g. Valdois et al., 2011). It has also been observed that some dyslexic children
suffer from disturbances in contrast sensibility (Lovegrove, Bowling, Badcock, &
Blackwood, 1980), weak sensitivity in detecting coherent motion or forms
(Cornelissen et al., 1995), or a visuo-attentional deficit (Bellocchi, Muneaux,
Bastien-Toniazzo, & Ducrot, 2013; Vidyasagar & Pammer, 2010).

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

Visual Perception and Reading in Impaired Children

To successfully decode written words, beginning readers need to develop good

visual skills. In particular, to read new words by applying grapheme-to-phoneme
conversion rules, which is typical of the alphabetic stage, the child must be able
(1) to segment the fixated information. This means shifting from distributed
attention to more focused attention. Rapid serial encoding enables normal
grapheme/phoneme integration, that is, the ability to build a sublexical
representation automatically (e.g. Ruffino et al., 2010), and (2) to inhibit all
surrounding letters and words to reduce visual crowding—that is the
interference generated by stimuli in close proximity—and optimize letter
identification (Tydgat & Grainger, 2009). There is evidence that DD suffer more
from crowding than control children, and that one way to help these children
improve their reading comprehension is to increase inter-letter and inter-word
spacing (Zorzi et al., 2012).

Motor Skills and Reading: An Emergent Idea

Recent literature reports that motor skills may also be implicated in reading
acquisition. Indeed, gross motor skills are reported to have significant correlations
with reading (Knight & Rizzuto, 1993) and to facilitate children’s academic abilities
in reading, language, and mathematics (Son & Meisels, 2006). Moreover, Son and
Meisels (2006) observed that in early kindergarten, fine motor skills (especially
visual motor skills and manual dexterity/hand–eye coordination) predict
achievement in reading at the end of first grade. A study of two groups of preschool
children who were learning letters either by handwriting or by typing strengthens
this idea of the strong motor implication in reading (Longcamp, Zerbato-Poudou, &
Velay, 2005). These authors observed that training in handwriting gave rise to
higher letter-recognition performance than training in typing.
Some studies have established relationship between a motor-skill deficit and
reading difficulties. Dyslexics proved less successful than their peers at carrying
on motor tasks (for a review, see Jover et al., 2013). For instance, participants with
DD demonstrated poor performance on the Movement Assessment Battery for
Children (M-ABC; Iversen, Berg, Ellertsen, & Tønnessen, 2005), pegboard tasks
(Nicolson & Fawcett, 1994), bead threading (Fawcett & Nicolson, 1995), pointing
(Velay, Daffaure, Giraud, & Habib, 2002), and motor-learning tasks (Bennett,
Romano, Howard, & Howard, 2008). In graphomotor and handwriting tasks,
children with DD exhibited more variation at the intra-individual level in writing
a continuous repetitive alternated sequence of cursive letters (Borella et al.,
2011) or reproducing a character (Lam, Au, Leung, & Li-Tsang, 2011). Finally,
epidemiological studies demonstrate a rate of comorbid diagnosis of
developmental coordination disorder (DCD) in 16% (Kaplan, Dewey, Crawford,
& Wilson, 2001) to 70% (Iversen et al., 2005) of children with DD and, reading
disability has been observed in 29 to 70% of children diagnosed with DCD
(O’Hare & Khalid, 2002). Developmental coordination disorder pertains to
difficulty with various aspects of motor skills, from walking, overall co-ordination,
and balance to fine abilities such as drawing or writing (e.g. Huau, Velay, & Jover,
2015). Note that theories of atypical brain development (Gilger & Kaplan, 2001)
and procedural learning disorder (e.g. Nicolson & Fawcett, 2007) have both
proposed a partially common origin of DD and DCD.

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

 S. Bellocchi et al.

To sum up, in addition to the well-documented importance of phonological skills

in reading acquisition and dyslexia, visual perceptual and motor skills also appear as
important factors in learning to read. Evaluating these skills is therefore an
important challenge for dealing with reading impairment. Indeed, there is strong
evidence suggesting that the problems experienced by elementary schoolers and
older children in learning to read are related to the pre-literacy skills that they
bring with them from preschool and kindergarten (Lonigan, 2006). It therefore
seems important to find a reliable and practical test that could assess both visual
perception and motor skills. At the current time, most tools available to
professionals are designed for the evaluation and remediation of child language
problems (Goswami & Bryant, 1990). Furthermore, there are very few tools today
that focus on the assessment of visual perception for clinical purposes. Most of the
findings suggesting a link between visual processing and reading are from studies
implying specific experimental paradigms that rarely have a direct clinical
application in terms of standardized diagnostic tools (but see, Ducrot et al., 2008;
Leibnitz, Ducrot, Grainger, & Muneaux, 2014; Valdois, Guinet, & Embs, 2014).
We assume that it could be useful to evaluate visual–perceptual and motor
processing in order to better describe and understand dysfunctions or abilities
in children with DD, particularly when it is associated with DCD. Furthermore,
a battery assessing visual–perceptual and motor processing could help identify
children at risk for reading impairment at an early age and consequently
successfully plan educational intervention.

Developmental Test of Visual Perception Version 2: A Suitable Battery to Assess

Visual-Perceptive and Fine Motor Skills

The DTVP (Maslow, Frostig, Lefever, & Whittlesey, 1964) could be suitable for the
purposes mentioned previously. The second edition, DTVP-2 (Hammill et al.,
1993), can be administered to children between 4 and 10; 11 years of age, and
gives a measure of visual cognitive functions, while distinguishing between
visual–perceptual and visual–motor integration skills. Half of the subtests are
designed to test visual–motor integration and provide a Visual–Motor Integration
quotient (VMI). The other subtests are designed to test perceptual skill free of
motor control, and furnish a Motor Reduced Visual Perception quotient (MRVP).
Beyond specifically assessing visual–perceptual and fine motor skills, the DTVP
has been reported in the scientific literature as suited for studying normal and
pathological development (e.g. Gruber, Meixner, Prosser, & Sick, 2012;
Schoemaker et al., 2001; Valtonen, Dilks, & McCloskey, 2008). Bonifacci (2004)
found a significant difference in VMI between children with high and low gross
motor skills, in the absence of significant differences in perceptual skills or
intellectual ability. This result suggests that DTVP-2 can identify the specific
cognitive profile of children suffering from gross motor difficulties but with normal
visuo-perceptual skills. The DTVP battery has been also used to assess visual
perception and VMI in children with Attention Deficit Hyperactivity Disorder
(ADHD). In particular, Jung and collaborators (2014) recently suggested that
among children with ADHD, visual perception is lower in those children with
comorbid sensory processing disorder. Thus, visual perception may be related
to sensory processing, especially in the reactions of the vestibular and

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

Visual Perception and Reading in Impaired Children

proprioceptive senses. To our knowledge, no visual–perceptual and visual–motor

integration assessment has been done using the DTVP on children with DD.

The present study

The following three studies were run to find out whether DTVP-2 is a suitable tool
for investigating links between visual perception, visual–motor integration, and
reading development, and to distinguish between the different cognitive profiles
of children with developmental disabilities (i.e. DD and DCD). First, we wanted
to determine which, among phonological awareness, visual perception, and
visual–motor integration assessed in typically developing kindergartners, are the
best predictors of reading outcomes in first grade. Second, we aimed to see if
these abilities can be regarded as clinical markers in a group of dyslexic children.
Third, we wanted to describe specific cognitive profiles among DD (associated
or not with DCD) and DCD children in order to discuss the specific status of
comorbid children. In this condition, we also wanted to test if general visual
perception across the subcomponents of visual–motor integration and motor-
reduced visual perception assessed by DTVP-2 can dissociate reading impairment
with or without motor impairment (in particular DCD).
All the three studies were conducted in accordance with the Declaration of
Helsinki (WHO, 2008), approved by the local Ethics Committee Review Board
(Comité de Protection des Personnes pour la recherche biomédicale, CNRS,
France). The children’s parents gave their written consent for participation.

STUDY 1

In the first study, we used a longitudinal design to find out if visual perception and
visual–motor integration assessed with DTVP-2 in kindergarten would predict
reading outcomes of children in first grade.

Method

Participants
A total of 36 children took part in this study (mean age in months: 64.2,
SD = 3.9 months at the first assessment; mean age in months: 82.2, SD = 3.9 months
at the second assessment). They were all selected and recruited from mainstream
schools in a city in southern France. They were native speakers of French and had
normal or corrected-to-normal vision; none suffered from any neurological,
psychiatric, or emotional disorders or were educationally disadvantaged. We
excluded children who were considered by their teachers as either having
learning, cognitive, or behavioural difficulties (i.e. children who exhibited
attentional or other behavioural problems in class). We also excluded children
having neurodevelopmental disabilities (i.e. specific language impairment).

Material
Each participant received the following assessments:

(1) Visual perception skills using DTVP-2. Participants’ performance was assessed
according to the scoring key provided in the test manual (Hammill et al.,

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

 S. Bellocchi et al.

1993).1 Overall, DTVP-2 yields a general visual perception (GVP) quotient,

which is a composite of the MRVP and VMI quotients. Four subtests were
used to measure MRVP because they require little or no motor ability.
The child is asked to point to one or more target stimuli (a geometrical
figure or a simple shape like a star) mixed in with others that have been
modified in different ways, as follows: (1) position in space (PS): the target
figure is presented among others identical to it but differently oriented; (2)
figure-ground (FG): the target stimulus is embedded in a general sensory
background; (3) visual closure (VC): the stimulus figure, a partially completed
drawing, is presented among others similar to the target figure; (4) form
constancy (FC): the matching shape is presented among other shapes
modified in size, orientation, and other parameters. The other four subtests
were used to measure VMI. The child is asked to draw lines and figures of
increasing difficulty in different situations: (1) eye–hand coordination (EHS):
the child is requested to draw straight and curved lines between defined
visual boundaries; (2) copying (CO): the child is asked to draw of a set of
designs; (3) spatial relations (SR): the child is asked to join dots in order to
reproduce a model; (4) visual motor speed (VMS): the child is asked to draw
appropriate marks (cross and parallel lines) in a many corresponding designs
as fast as possible speed.
Raw scores for each subtest are corrected for age in order to obtain a standard
score (quotients: mean = 100; SD = 15; standard scores for each subtest:
mean = 10; SD = 3).The time required for this assessment was 30 min.

(2) Phonological awareness. We used two subtests of the French test the New
Language Examination Battery (Chevrie-Muller & Plaza, 2001). In the ‘Phoneme
Identification Task’, the children were asked to identify the initial phoneme of
15 disyllabic words, 10 with vowels and five with consonants (/v, l, p, r, s/) in
initial position (e.g. /a/ in ‘ami’—‘friend’, /l/ in ‘lapin’—‘rabbit’). We also
administered the ‘Rhyme Task’ composed of 8 items in which the child heard
two words and had to say if they rhymed. The experimenter gave two
examples for each task and recorded accuracy for each item, with 0 for errors
and 1 for correct responses. The time required for this assessment was around
15 min.
(3) Reading outcomes using the ‘Alouette Test-R’ (Lefavrais, 2005). This test is
commonly used in France to assess reading proficiency. Participants are
instructed to read the text as fast and as accurately as possible. The test
provides two z-scores, one based on fluency (number of words correctly read
in 3 min) and the second on accuracy (reading errors being taken into
account). The time required for this assessment was 5 min.

Procedure
In this longitudinal study, two-step assessment procedure was run. At each testing
step of the study, children were withdrawn from their classrooms. At Time 0
(middle of kindergarten), children were individually administered DTVP-2, the
‘Phoneme Identification’ and ‘Rhyme’ tasks. One year and 4 months later, at Time
1 (end of Grade 1), the same children were individually administered the ‘Alouette
Test-R’.

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

Visual Perception and Reading in Impaired Children

Results

Table 1 shows the means and standard deviations of each standard composite
measure of DTVP-2 (MRVP, VMI, and GVP), and of the ‘Phoneme Identification’
and ‘Rhyme’ tasks from the first assessment. These five measures were taken as
predictors of reading abilities, assessed with the ‘Alouette Test-R’, such as
accuracy and fluency scores. Means and standard deviations of the reading
measures are also presented in Table 1. Statistical analyses were conducted using
the SPSS ® program, version 20.0.
A bivariate correlation between all measures assessed in kindergarten and in
Grade 1 was run (Table 2). The results indicated significant correlations between
phonological awareness measures and reading outcomes, as well as between VMI
and reading outcomes, in particular reading accuracy. No significant correlation
emerged between MRVP and reading outcomes. Moreover, there were no
significant correlations between phonological predictors and the two
subcomponents of visual perception taken separately (i.e. visual–motor
integration and motor-reduced visual perception).
At a later time, a step-wise linear regression analysis (enter method) was
carried out to identify significant visuo-perceptual and phonological predictors of
first grade reading outcomes. All predictors were entered simultaneously. Then,
all variables that were not relevant to the model were removed. Separate analyses
were run for each outcome variable measuring reading abilities. Thus, two
regression analyses were run in all.

Reading accuracy
The analysis revealed that both phonological and visual–perceptual skills
significantly predicted reading outcomes in Grade 1. In particular, the Rhyme score
(ß = .40, p < .05) and the VMI score (ß = .33, p < .05) were significant predictors
of reading accuracy. The model with the Rhyme score only accounted for about
23% of the variance [(R2 = .23); F(1,35) = 11.31, p < .05]. However, the model with
both the Rhyme score and the VMI quotient accounted for about 31% of the
variance in the test scores [(R2 = .31); F(2,35) = 8.9, p < .001]. Tests to find out
whether the data met the assumption of collinearity indicated that
multicollinearity was not a concern (Rhyme score, tolerance = .91, VIF = 1.10;
VMI score, tolerance = .91, VIF = 1.10).

Table 1. Means and standard deviations of all variables included in the regression analyses: DTVP-2
composite measures (MRVP, VMI, and GVP), phoneme identification and rhyme performance
(z-scores) assessed in kindergarten, and reading skills (z-scores) assessed in Grade 1
Kindergarten Grade 1
Mean (SD) Mean (SD)
MRVP (quotient) 100.5 (10.6) —
VMI (quotient) 113.6 (14.7) —
GVP (quotient) 107.1 (10.9) —
Phoneme identification (z-score) 0.1 (1.1) —
Rhyme (z-score) 0.3 (1.1)
Reading accuracy (z-score) — 0.2 (1.1)
Reading fluency (z-score) — 0.8 (1.2)
Chronological age (months) 64.2 (3.9) 82.2 (3.9)

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 S. Bellocchi et al.

Table 2. Bivariate correlations between all measures [DTVP-2 composite measures (GVP, MRVP
and VMI), phoneme identification, rhyme performance (z-scores), and reading outcomes] assessed,
respectively, in kindergarten and in Grade 1
Phoneme
Accuracy Fluency Rhyme identification GVP MRVP VMI
(z-score) (z-score) (z-score) (z-score) (std. score) (std. score) (std. score)
Accuracy 1 .632** .500** 0.306 0.203 0.161 .456**
(z-score)
Fluency .632** 1 .465** .497** 0.089 0.14 0.19
(z-score)
Rhyme .500** .465** 1 .553** .336* 0.154 0.304
(z-score)
Phoneme 0.306 .497** .553** 1 .544** 0.268 0.304
identification
(z-score)
GVP 0.203 0.089 .336* .544** 1 .720** .635**
(std. score)
MRP 0.161 0.14 0.154 0.268 .720** 1 .598**
(std. score)
VMI .456** 0.19 0.304 0.304 .635** .598** 1
(std. score)

**Correlation is significant at the 0.01 level (2-tailed).

*Correlation is significant at the 0.05 level (2-tailed).

Reading fluency
Here, the analysis revealed that only the Phoneme Identification score (ß = .50,
p < .05) was a significant predictor of reading fluency at the end of Grade 1. This
predictor accounted for about 22% of the variance in the test scores [(R2 = .22);
F(1,35) = 11.2, p < .05]. Tests to see whether the data met the collinearity
assumption indicated that multicollinearity was not a concern (Phoneme
Identification score, tolerance = 1, VIF = 1).

Discussion
This longitudinal study showed, as is well documented in the literature, that
phonological awareness predicts reading outcomes one year later. However,
more interestingly, these results also showed that visual-perception skills
contribute to predicting the development of reading abilities, which is in line with
other studies (e.g. Son & Meisels, 2006). In particular, VMI subcomponent,
assessed in kindergarten, predicted reading outcomes one year later. The better
a child’s visual–motor integration skills are, the better his/her reading abilities will
be. In other words, this component contributed to understanding skills involved in
the development of reading, because it increased the variance explained by the
regression models. The importance of phonological and orthographic skills in
learning to read (e.g. Goswami & Bryant, 1990; Snowling, 2000; Vellutino et al.,
2004) should not overshadow the fact that visual–motor integration skills also play
a significant role to successfully decode written words. Note that no significant link
between motor-reduced visual-perception and reading outcomes was obtained. In
this study, we used a prospective, longitudinal approach where visual perception,
visual–motor integration, and phonological awareness were measured in

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Visual Perception and Reading in Impaired Children

pre-readers, and the impact of these skills on future reading development was
explored. The results suggest that beyond phonological awareness visual–motor
integration abilities are predictors of reading development.
Finally, it is important to remember that general intelligence can mediate the
relationship between predictors (phonological awareness, visual perception,
visual–motor integration) and reading outcomes (e.g. see van den Bos (1998) on
the relationship between word identification variables, intelligence, phonological
awareness, and continuous-naming speed). To comply with the rules of the Board
of Education, we were not allowed to carry out intelligence tests on children
attending mainstream classes. Because we did not have intelligence measures,
we cannot totally rule out the possibility that other cognitive differences between
the children affected the result pattern we obtained. However, all of the children
were attending normal classes, and no child had any reported history of learning
or cognitive deficits or neurodevelopmental disabilities (i.e. specific language
impairment).

STUDY 2

This second study was aimed at assessing visual perception and visual–motor
integration using DTVP-2 in children with DD, as compared to typically developing
children matched on chronological age or reading level.

Method
Participants
Sixty children participated in the experiment. They were divided into three
groups: one of 20 dyslexics (DD) (mean age in months = 114.3; SD = 11.3) and
two control groups each composed of 20 typical developing readers, the first of
which was matched on chronological age (CA) (mean age in months = 114.8;
SD = 11.6) and the second of which was matched on reading level (RL) (mean
age in months = 83.3; SD = 5.8).
Dyslexic children were recruited and diagnosed at La Timone University
Hospital in Marseille, France. They all underwent a complete medical,
psychological, and cognitive assessment. Criteria for inclusion in the sample were
manifest reading deficits (at least 1.5 SDs below the normal level) on the ‘Alouette
Test-R’ (Lefavrais, 2005), an IQ level measured on the WISC-IV (French version
by ECPA, Wechsler, 2005) within the normal limits set by the diagnosis unit
(IQ > 85), and no visual or hearing deficits. They were not included in the study
if their oral language skills were in the pathological range or if they were diagnosed
with ADHD.
The participants in the control groups were recruited from an elementary
school (Grade 1 through 5) in a city in southern France, according to their reading
level (Grade 1 or 2) and chronological age (Grade 4 or 5) of the dyslexic children.
None suffered from any neurological, psychiatric, or emotional disorders or were
educationally disadvantaged. The inclusion criteria were a normal reading level and
no visual or hearing deficits. We did not include children who were considered by
their teachers as having either a specific learning deficit or cognitive and
behavioural problems.

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 S. Bellocchi et al.

All participants were native speakers of French with normal or corrected-to-

normal vision. As we noted by post-hoc analyses, the mean reading level of the
dyslexic children (mean = 84.7 months; SD = 7.3 months) was significantly below
the mean reading level of the chronological age matched group
(mean = 123.2 months; SD = 26.2 months; p < .001). However, as expected,
the mean reading level of the dyslexic children was not significantly different from
that of the reading-level matched children (mean = 84.8 months; SD = 4.6; p = n.s)
(ANOVA; group effect: F(2,59) = 38.9; p < .001).

Material
Each participant underwent DTVP-2 and ‘Alouette Test-R’ described in Study 1.

Procedure
All children were tested individually: dyslexics were tested at the hospital and
normal readers, in their schools. The session lasted about 45 min.

Results
In order to compare developmental dyslexics’ (DD) visual perception and VMI
skills with normal readers’ skills (CA and RL groups), we ran a multivariate analysis
of variance (MANOVA) on the MRVP, VMI, and GVP quotients, with group (DD,
CA, and RL) as a between-participants factor. Statistical analyses were conducted
using the SPSS ® program, version 20.0. Table 3 gives the means and standard
deviations of the MRVP, VMI, and GVP quotients for each group.
The results indicated a significant group effect on all three indexes: GVP
quotient (F(2, 59) = 23.9; p < .001, MSE = 0.5), MRVP (F(2, 59) = 11.7; p < .001,
MSE = 0.3), and VMI (F(2, 59) = 35.4; p < .001, MSE = 0.5). The dyslexics’ GVP
scores were lower than the RL’s scores (p < .001; Bonferroni post-hoc tests).
The same result was found for MRVP (p < .001; Bonferroni post-hoc tests) and
VMI (p < .001; Bonferroni post-hoc tests). Likewise, comparisons between the
DD and CA matched groups yielded the same trend. Dyslexics’ GVP sores were
lower than the CA’s scores (p < .001; Bonferroni post-hoc tests). Here again,
significant differences emerged for MRVP (p < .001; Bonferroni post-hoc tests)
and VMI (p < .001; Bonferroni post-hoc tests). RLs and CAs did not differ
significantly on GVP or MRVP, but RLs outperformed CA’s on VMI (p < .05).

Table 3. Mean scores and standard deviations of the dyslexics (DD), the reading-level matched group
(RL), and the chronological-age matched group (CA) on the DTVP-2 composite measures (MRVP,
VMI, and GVP) (quotients)

DD RL CA
(n = 20) (n = 20) (n = 20)
Mean (SD) Mean (SD) Mean (SD)
MRP (quotient) 88.3 (14.5) 109.2 (14.4) 105.1 (14.5)
VMI (quotient) 96.4 (10.1) 123.6 (10.0) 114.0 (10.9)
GVP (quotient) 91.9 (10.9) 117.0 (12.1) 109.7 (12.2)

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

Visual Perception and Reading in Impaired Children

Discussion

DD children exhibited lower visual-perception and visual–motor-integration skills

as compared to CA, and more importantly, RL matched controls. Here, the
dyslexics performed significantly less well than the RL controls, which means that
the observed visual–perceptual and visual–motor difficulties might not be simply a
consequence of poor exposure to reading but a marked and basic disorder
underlying DD (Goswami, 2014). Additional analysis showed that three dyslexics
(15%) in our group had scores less than or equal to 85 on the VMI subcomponent,
nine (45%) had scores less than or equal to 85 on the MRVP, and finally, seven
(35%) were in that range on the GVP composite score. These profiles could be
the manifestation of subclinical deficits (or global visual-processing weaknesses)
or, in some cases, could be hidden deficits in the presence of a developmental
disorder that has not been identified yet.
The results are further discussed in the General discussion section while taking
into account the results obtained from the third study.

STUDY 3

In this third study, we compared visual perception and visual–motor integration,

as assessed using DTVP-2, of a group of children with DD, a group with DCD,
and a group with the both developmental disorders.2 Our goal was to describe
specific profiles among DD and DCD children in visuomotor or visuospatial
processing. We also wanted to describe the status of comorbid children
DD + DCD.

Method

Participants
In all, 47 children participated in the experiment. Participants were recruited and
diagnosed at La Timone University Hospital in Marseille, France. All underwent a
complete medical, psychological, and cognitive assessment. All participants were
native speakers of French with normal or corrected-to-normal vision. Children
whose oral language skills were in the pathological range or who were diagnosed
with ADHD were excluded from the study. Three groups of participants were set
up. (1) A group of 24 dyslexics (mean age in months = 121.9; SD = 13.9). Criteria
for inclusion were manifest reading deficits (at least 1.5 SDs below the normal
level) on the ‘Alouette Test-R’ (Lefavrais, 2005), on IQ measured on the WISC-
IV (French version by ECPA, Wechsler, 2005) within the normal limits set by
the diagnosis unit (IQ > 85) and no deficits in vision or hearing. More importantly,
we selected children without a DCD. (2) A group of 12 DD children with DCD
(mean age in months = 118.1; SD = 14.2). Regarding a potential reading deficit,
criteria for inclusion were manifest reading deficits and IQ within the normal limits
set by the diagnosis unit (IQ > 85), and no vision or hearing deficits. Children were
identified as displaying DCD if they had a score below the 15th percentile on the
French version of the M-ABC (Soppelsa & Albaret, 2004), an IQ within normal
limits (IQ > 85), and no vision or hearing deficits. (3) A group composed of 11
children with DCD only (mean age in months = 116.4; SD = 14.8). We selected

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 S. Bellocchi et al.

children who were diagnosed as DCD on the basis of the criteria listed above, i.e.
score on the M-ABC below the 15th percentile, on IQ within the normal limits set
by the diagnosis unit (IQ > 85), and no vision or hearing deficits. We excluded
children with DD or reading difficulties.
A detailed description of participants’ reading abilities and motor skills is
available in Table 4.
As expected, post-hoc analyses showed that the mean reading abilities (both
accuracy and fluency) of the dyslexic children were significantly lower than the
DCD’s mean reading abilities (accuracy: p < .05; fluency: p < .001) but were
not significantly lower than that of the DD + DCD children (p = n.s.). DD + DCD’s
mean reading abilities were significantly lower than that of the DCD children
(accuracy: p < .05; fluency: p < .001) (MANOVA; group effect—accuracy:
F(2,46) = 7.6; p < .05; fluency: F(2,46) = 16.5; p < .001). Similarly, the dyslexic
children’s mean percentile on motor performance was significantly higher than
those of the DCD and the DD + DCD children (p < .001). The difference
between DCD and DD + DCD children was not significant (p = n.s.) (MANOVA;
group effect: F(2,46) = 16.3; p < .001).

Material
Each participant was given DTVP-2 described in Study 1.

Procedure
All children were tested individually at the La Timone Hospital. The session lasted
about 45 min.

Results
In order to compare the performance on visual perception and VMI of children
with developmental disorders, we ran a MANOVA on the MRVP, VMI
subcomponents, and GVP, with group (DD, DD + DCD, and DCD) as a
between-participant factor. Figure 1 shows the means and standard deviations of
the quotients in each group. Statistical analyses were conducted using the SPSS ®
program, version 20.0.
The results indicated a significant group effect on the GVP quotient
(F(2, 45) = 9.9; p < .001, MSE = 0.3), MRVP (F(2, 45) = 4.1; p < .05, MSE = 0.2),
and VMI (F(2, 45) = 15.1; p < .001, MSE = 0.4). With regard to the GVP quotient,

Table 4. Participants’ mean scores (standard deviations) on the ‘Alouette Test-R’ and M-ABC

DD DD + DCD DCD
(n = 24) (n = 12) (n = 11)
Mean (SD) Mean (SD) Mean (SD) MANOVA
Chronological age (months) 121.9 (13.9) 118.1 (14.2) 116.6 (14.8) —
Alouette Test-R (reading accuracy/ z-score) 1.9 (1.7) 2.1 (1.3) 0.0 (0.8) p < .05
Alouette Test-R (reading fluency/ z-score) 1.6 (0.6) 1.5 (0.5) 0.2 (1.6) p < .001
M-ABC (percentiles) 34.9 (26.7) 3.6 (2.6) 1.7 (1.4) p < .001

Note: DD = children with DD only; DD + DCD = children with DD and DCD; DCD = children with DCD only.

Copyright © 2017 John Wiley & Sons, Ltd. DYSLEXIA (2017)

Visual Perception and Reading in Impaired Children

Figure 1. DD, DD + DCD and DCD children’s quotients on DTVP-2 components (error bars
indicate standard deviations). Note. MRVP = motor-reduced visual perception; VMI = visual-motor
integration; GVP = general visual perception. DD = children with DD only; DD + DCD = children
with DD and DCD; DCD= children with DCD only.

group DD outperformed groups DD + DCD and DCD (p < .05 and p < .001,
respectively; Bonferroni post-hoc test). No significant differences were found
between groups DD + DCD and DCD. The VMI results showed the same trends:
DD children outperformed DD + DCD and DCD children (p < .05 and p < .001,
respectively; Bonferroni post-hoc test) with no significant difference between
groups DD + DCD and DCD. For the MRVP, only the difference between the
DD and DCD children’s scores was significant (p < .05; Bonferroni post-hoc test).

Discussion
The results of this third study showed that dyslexic children got higher scores on
general visual perception than did dyslexics with DCD and children with a DCD
only (with no significant difference between DD + DCD and DCD children).
Regarding the subcomponents, the children with DCD (associated or not with
dyslexia) obtained lower VMI scores than the dyslexics did. The presence of a
motor disorder (associated or not with dyslexia) seems to be sufficient to
negatively affect VMI, thus suggesting that this is not the association of DCD and
another neurodevelopmental disorder that determines the presence of
visuomotor impairment, but rather the occurrence of DCD in itself. Moreover,
DCD children got lower MRVP quotient than DD. These results suggest that
the MRVP subcomponent can discriminate between isolated disorders, in
particular between children with DD only and DCD only. In this vein, sensory-
perceptual dysfunctions, which include visuo-sensory processing, visuo-spatial
processing, and basic processing speed, have been frequently demonstrated in
DCD (for a review, see Wilson et al., 2013). Note that, for all the quotients,
comorbid children performed at an intermediate level between DD and DCD
children. The absence of significant group differences between co-morbid children
and DD (MRVP) or DCD (GVP, MRVP, and VMI) children suggests that the co-
morbid condition does not add to the severity of each deficit (Biotteau, Albaret,
Lelong, & Chaix, 2016; Kaplan et al., 2006).
The same results have been found with an additional analysis on individual
differences. We found that none of the dyslexic children had scores below 70
on DTVP-2 and only two dyslexics (8.3%) had scores between 70 and 85 on
GVP. Among the children with DD and DCD, five (41.7%) had scores between
70 and 85 on GVP, six (50%) had scores between 70 and 85 on MRVP and VMI.

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 S. Bellocchi et al.

Finally, for group DCD, one child (9%) and three children (27.3%) had scores
under 70 on GVP, MRVP, and VMI. Four children (36.4%), one child (9%), and
three children (27.3%) had scores between 70 and 85 on GVP, MRVP, and VMI.
Note that, contrary to Study 2, there were no children in the DD only group with
a VMI or MRVP quotient below 85.

GENERAL DISCUSSION

One of the main goals of the present study was to explore the clinical usefulness of
DTVP-2 in (1) exploring which among phonological, visual-perception, and visual–
motor factors, are the best predictors in learning to read, (2) describing specific
cognitive profiles among children with reading impairments (i.e. DD) in order to
improve diagnostic assessment and, (3) describing specific cognitive profiles among
DD (associated or not with DCD) and DCD children in order to discuss the
specific status of comorbid children. This third study was also aimed at determining
whether is able to differentiate between DD children with and without DCD when
controlling with more severe inclusion criteria. To the best of our knowledge, this is
the first study investigating the validity of DTVP-2 for predicting reading outcomes.
Furthermore, among developmentally disabled children, there are no studies
assessing visual perception and visual–motor integration using the DTVP, not even
on children with DD. In this work, we thus employed a comprehensive approach
that incorporates almost all of the accepted methods required to test the
relationship between visual perception, visual–motor integration, and reading
acquisition (Goswami, 2014).
First, this longitudinal study showed that beyond linguistic abilities such as
phonological awareness, VMI subcomponent, assessed in kindergarten, predicts
reading outcomes in first grade. In other words, this component contributes to
our understanding of the skills involved in the development of reading, because it
increased the variance explained by the models tested here. These results confirm
that, to learn to read, children must develop good linguistic skills such as phonological
awareness (e.g. Goswami & Bryant, 1990; Snowling, 2000; Vellutino et al., 2004).
Furthermore, these results showed that children also need to develop good visual–
motor integration skills in order to be able to successfully decode written words.
Note that the results of this first study did not reveal any predictive link between
motor-reduced visual-perception and reading outcomes.
More specifically, how can we explain the relationship between visual–motor
skills and reading? As stated in the Introduction section, Son and Meisels (2006)
observed that fine motor skills in early kindergarten, especially visual–motor ones
like manual dexterity and hand–eye coordination, predict achievement in reading
at the end of first grade. In this vein, the study of two groups of preschool children
who were learning letters either by handwriting or by typing strengthened the idea
of a substantial motor implication in reading (Longcamp et al., 2005). In that study,
the authors observed that handwriting training gave rise to higher letter recognition
performance than typing training. The hypothesis that letters are learned through
the matching of a visual configuration and movements was taken into account in
interpreting these interesting results, which suggest that letters are not represented
solely by their visual characteristics but more broadly on the basis of a multimodal
representation in which one of the components is sensorimotor in nature.

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Visual Perception and Reading in Impaired Children

Accordingly, the results of our Study 1 can be interpreted by taking into account the
hypothesis of the impact of visual–motor skills on reading acquisition, via their
contribution to letter recognition (Longcamp et al., 2005). Note, however, that
we cannot exclude the possibility that other cognitive underpinnings such as
working memory or procedural learning could mediate this relationship and impact
reading acquisition (e.g. Memisevic & Sinanovic, 2013; Nicolson & Fawcett, 2011).
From a clinical perspective, the results of this first study have important
implications because they show that academic skills (i.e. reading) develop partly
by interacting with visual–motor integration skills. In practice, these results
suggest that it would be useful to assess visual–motor integration skills for
developmental screening in kindergarten as one element of a larger battery.
Indeed, DTVP-2 is capable of successfully identifying variability in reading
acquisition among children. We can thus speculate that at least some
subcomponents of DTVP-2 might be relevant for identifying children at risk for
reading difficulties, although this needs further studies and clarified in the future.
Sensory theories of DD suggest that the basis of this disorder is a deficit that is
sensory in nature (e.g. Goswami, 2011; Ramus, 2004; Stein & Walsh, 1997). The
hypothesis that a sensorimotor component is involved in learning to read could
explain the results obtained in our second study. We found that dyslexics showed
lower motor-reduced visual-perception and visual–motor integration skills than
normal readers. These findings are in line with the results of the other studies
presented in the Introduction section, which showed that a number of dyslexics
present a visual-processing deficit and have more difficulty than their peers taking
tests assessing visual–motor integration (Fawcett & Nicolson, 1995; Nicolson &
Fawcett, 1994; Velay et al., 2002). According to Ramus (2004), motor impairments
and perceptual deficits can be viewed as an associated sensorimotor syndrome
caused by an abnormal cytoarchitectonic structure in subcortical areas. This so-
called nonspecific marker model states that the core cognitive symptoms of
dyslexia (the phonological deficit) originate from abnormalities of neural migration
located in left perisylvian areas involved in phonological processing. The associated
sensory symptoms of dyslexia (i.e. visual, motor, or auditory) originate from
subcortical abnormalities in (possibly magnocellular) sensory pathways,
particularly the thalamus. Possibly, motor symptoms might arise from a further
spread of disruption from the thalamus to the cerebellum (Stein & Walsh, 1997).
First, the results of our second study underline and confirm the importance of
the motor subcomponent of visual perception in learning to read. Second, in line
with one of the main aims of this research, the present results point out the clinical
usefulness of DTVP-2 as a specific battery for evaluating visual–perceptual and
motor skills in order to describe the abilities and disabilities of children that have
already received a diagnosis of DD. The possibility of describing specific cognitive
profiles in this population allows the clinician to improve diagnosis and
consequently to plan an ad hoc remediation and intervention program. In
principle, Ramus (2004) suggests that his nonspecific marker model might apply
not only to dyslexia, but to any neurodevelopmental disorder with relatively
specific cognitive symptoms (possibly arising from similar cortical abnormalities
in different locations) and associated sensorimotor deficits. This hypothesis offers
potential explanations for the frequent association of specific neurodevelopmental
disorders and sensorimotor manifestations, heterogeneity within each disorder,
and disorder comorbidity.

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 S. Bellocchi et al.

Within this theoretical framework, we will discuss the results of Study 3.

Overall, the results of our third study showed that DD children had higher
scores on general visual perception compared to DD + DCD and DCD
children. With regard to the subcomponents, children with DCD got lower
MRVP scores than DD. Moreover, children with DCD (associated or not with
dyslexia) obtained lower VMI scores than dyslexic children. The above findings
suggest that these two DTVP-2 subcomponents reflect different cognitive
profiles. In other words, the presence of a motor disorder (associated or not
with dyslexia) seems to be sufficient to negatively affect VMI. From the
standpoint of DCD, these results suggest that contrary to Crawford and
Dewey’s (2008) findings, it is not the association between DCD and another
neurodevelopmental disorder that determines the presence of visual perception
deficits but rather the occurrence of DCD in itself. The presence of a DCD
(isolated or not) seems to affect general visual perception, assessed here by
the two subcomponents of DTVP-2. This was also confirmed by the additional
analysis on individual differences.
Taking the MRVP and VMI quotients into account, the DD and DCD results
clearly reveal inter-group variations only between the DD and DCD groups,
suggesting that DD and DCD are distinct disorders with unique characteristics.
DCD children seem to have more difficulty both in MRVP and VMI than do DD
children. These results are in agreement with previous studies showing visuo-
spatial impairment in DCD (Wilson & McKenzie, 1998; Wilson et al., 2013) but
efficient visuo-spatial abilities in DD (Bonifacci & Snowling, 2008; De Clercq-
Quaegebeur et al., 2010). They also extend Biotteau et al.’ (2016) results
suggesting that unlike DD, DCD involves a visuospatial deficit when a motor
component is required, even in the case of a motor-reduced task.
Moreover, it is important to underline that there are also some commonalities
between neurodevelopmental disorders. In particular, the absence of significant
group differences between the DD + DCD children and the DD or DCD
children suggests that the co-morbid condition does not add to the severity of
each deficit. Previous studies have reached the same conclusion, with no
cumulative impact on cognitive abilities in the case of a dual diagnosis (see
Biotteau et al., 2016, for a detailed review).
Finally, contrary to Study 2, in Study 3, there were no children in the DD
only group with a VMI or MRVP quotient below 85. One possible explanation
of the discrepant results between Study 2 and Study 3 can be found in the
inclusion criteria used in the selection of the DD children. In Study 2, motor
comorbidity was not evaluated. In Study 3, we controlled for more severe
inclusion criteria concerning the presence/absence of associated motor
impairment in the DD groups. This suggests that when controlling for co-
occurrence with DCD, dyslexics may show a different pattern of results
regarding MRVP or VMI. In particular, we can assume that the presence of
deficits in motor-reduced visual perception or visual–motor integration in
developmental dyslexia results from the comorbidity with DCD. In other words,
being dyslexic with an associated DCD seems to increase the possibility of
showing deficits in motor-reduced visual perception or visual–motor integration.
This point constitutes a critical issue that must be taken into account in future
studies exploring visual perceptual skills in individuals with developmental
dyslexia.

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Visual Perception and Reading in Impaired Children

CONCLUSIONS

The current study showed that DTVP-2 is a suitable tool for investigating links
between visual perception, visual–motor integration, and reading. It is also useful
for differentiating between the cognitive profiles of children with developmental
disabilities, while dissociating between reading impairment with or without
motor impairment, and for highlighting commonalities between children who
have comorbidity or isolated disorders. For these reasons, it seems suitable to
use DTVP-2 in the assessment of learning disabilities.

PRACTITIONER POINTS

• Literature suggests that DD is frequently associated with motor disorders, while

children with DCD show poor reading outcomes.
• In addition to phonological skills, we found that visual–motor integration was a
significant predictor of reading acquisition.
• We suggest that visual perception and visual–motor integration, as assessed by
DTVP-2, differentiate cognitive profiles of children with developmental disabilities.
• DTVP-2 dissociates between reading impairment with or without DCD, and
highlights commonalities between children who have comorbidity or isolated
disorders.

ACKNOWLEDGEMENTS

The authors are grateful to Mr Pierre Blache, inspector of French National

Education – Garlaban (Aix-Marseille Academy, France) for allowing us to run this
research in some of his mainstream elementary schools. We would also like to
thank Claire Gaillard, Agnes Gaussuin and Laetitia Filippi for their precious help
in collecting some of the data presented in this paper. We are very grateful to
the children and their parents who agreed to take part in this research.
We would like to thank Bernard Lété and Yves Chaix for their helpful
comments and feedback on the general discussion.
Support for this research was partly provided by a grant from the French
National Research Agency (ANR) DYSTAC-MAP.

ENDNOTES

1. At the time of this study, no French standardization of the DTVP-2 was available. This
forced us to refer to the USA norms and the English version of the test. We translated
the instructions from English to French.
2. The clinical purpose of this study justified the non inclusion of an unimpaired control group.

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