Case Study 3: A novel tool facilitating objective identification of children with motor control difficulties for timely treatment and support
Submitting InstitutionUniversity of Leeds
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
The `Clinical Kinematic Assessment Tool' (CKAT) is an innovative system
that detects the 5% of children with motor control problems who, as a
result, experience academic and social disadvantage — which increases the
likelihood of educational difficulties, anxiety and depression. CKAT's
development is led by Mon-Williams at the University of Leeds
(UoL), in partnership with the University of Aberdeen. Since 2012, CKAT
has been used in 88 primary schools in Bradford. All Reception Year
children (aged 4-5 years) are CKAT screened (~4,000 children annually)
with teachers using this information to prompt further assessment and
additional classroom support. CKAT is now being commercialised via a
licensing deal (2012) with a Scottish SME.
The abundance of motor skills that must be mastered in the course of
childhood (e.g. dressing, washing, feeding oneself, writing legibly) makes
it clear that motor coordination is a keystone of a child's developmental
progress. The consequences of impairment in motor ability are profound. A
wealth of research has shown that many of these children with motor
deficiencies have poor health and educational outcomes if they are not
identified in the early school years. Nonetheless, these children are
often missed or identified too late for optimal remedial action. Current
clinical practice guidelines produced by the European Academy of Childhood
Disability identify an urgent need for early identification of children
with developmental motor coordination difficulties (at 5 years of age) and
it is known that treatment is effective if children are identified early.
Unfortunately, large numbers of these children do not receive attention
because existing methods to measure motor skills rely on the subjective
evaluation of specialists using time consuming tools (Sugden, D.A. (2005).
Development Coordination Disorder as a Specific Learning Difficulty. ESRC
report. Retrieved from http://www.dcd-uk.org/images/LeedsConsensus06.pdf).
In response to this, a collaborative effort led by Mon-Williams
(Professor of Cognitive Psychology, UoL, 2009-present) and Williams
(University of Aberdeen) resulted in the development of the CKAT battery;
a system capable of detecting at risk children so that they can receive
intervention — IP protected by patent [A]. This system presents
visuomotor tasks whilst simultaneously recording responses via
interactions with a tablet screen using a pen-like stylus. CKAT uses
sophisticated processing algorithms (previously only available in research
laboratories) to generate outcomes describing the behaviour.
Since 2009, the UoL has led the physical development of CKAT. The
software  was written and developed by Culmer (School of
Engineering, UoL, 2003-present), supervised by Mon-Williams and
employed on grants held by Mon-Williams [i-iii] and UoL academics
are authors on all underpinning research [1-6]. The tasks
presented within the CKAT battery were conceived and designed by Mon-Williams
and implemented by Flatters (PhD student, UoL, 2009-2013), supported by a
grant to Mon-Williams [iv]. Data were collected and analysed in
Leeds (2010-present) to ensure that the system was capable of detecting
differences in motor skill acquisition and these data have been published
recently . This constitutes the first objective data detailing
differences between learning to generate a novel shape as a function of
training regime (copying versus tracing). The usefulness of the device in
measuring performance and motor strategies in young and old adults has
also been established, extending CKAT's impact to adults .
These activities were supported by grants to Mon-Williams:
Wellcome Trust (Anderson, Research Fellow, UoL, 2011), a Biomedical and
Health Research Centre grant (BHRC) [iv] and MRC post-doctoral
fellowship [v] to L.Hill (Research Fellow, UoL,
2011-present). To support rolling out of CKAT in schools (2012), a system
to provide feedback to teachers was designed and included as part of the
software by Flatters (funded by a grant to Mon-Williams [vi]).
Since 2012, Culmer and Flatters have been working with a Scottish SME to
produce a system for commercial use.
References to the research
 Culmer*, P.R., Levesley*, M.C., Mon-Williams*, M.,
& Williams, J.H.G. (2009). A new tool for assessing human movement:
The. Kinematic Assessment Tool. Journal of Neuroscience Methods 184,
184-192. doi: 10.1016/j.jneumeth.2009.07.025 Article detailing the
software architecture designed to present and deliver the CKAT battery.
 Wilkie*, R.M., Johnson*, R.L., Culmer*, P., Allen*, R.J.,
& Mon-Williams*, M. (2012) Looking at the task in hand impairs
motor learning. Journal of Neurophysiology, 108, 3043-3048. doi:
10.1152/jn.00440.2012 Demonstrates that distortions in the visual
feedback provided by CKAT affect the rate of learning for a manual task
using a stylus.
 Snapp-Childs, W., Mon-Williams*, M., & Bingham,
G.P. (2013) A sensorimotor approach to the training of manual actions in
children with developmental coordination disorder. Journal of Child
Neurology, 28(2), 204-212. doi: 10.1177/0883073812461945 Demonstrating
haptic robotic training improving manual control in children with
movement problems, as indexed by measuring performance after training on
a CKAT handwriting task.
 Williams, J.H.G., Mon-Williams*, M., Culmer*, P.,
Casey, J., & Braadbaart, L. (2013) Kinematic measures of imitation
fidelity in primary school children. Journal of Cognition and
Development. doi: 10.1080/15248372.2013.771265 Presents a novel
method for measuring imitation accuracy in children using CKAT.
 Gonzalez*, C., Anderson*, J., Culmer*, P., Burke*, M.R.,
Mon-Williams*, M., & Wilkie*, R.M. (2011) Is tracing or
copying better when learning to reproduce a pattern? Experimental
Brain Research, 208 (3), 459-465. doi: 10.1007/s00221-010-2482-1 Presents
manual control data collected via the CKAT system and details the
differences in producing a novel shape when copying versus tracing (as
required in handwriting acquisition).
 Raw*, R.K., Kountouriotis*, G.K., Mon-Williams*, M.,
& Wilkie*, R.M. (2012). Movement control in older adults: does
old age mean middle of the road? Journal of Experimental Psychology:
Human Perception and Performance, 38(3), 735-45. doi:
10.1037/a0026568 Demonstrates CKAT battery scores related to
performance and strategy in older adults.
Key funding and grants
[i] Department of Health NEAT Programme. (2008-2010). Novel
Interactive Peer Group Therapeutic Activities System for Children with
Cerebral Palsy. Levesley*, M., Bahkta*, B.B., Mon-Williams,* M.,
Cozens, J.A., Richardson*, R.C., Sugden*, D., & Clarke*, M. £449,000.
[ii] Scottish Government (Scottish Enterprise). (2005-2007). A
standardised tool for the assessment of neurodevelopmental disorder.
Williams, J.H.G., & Mon-Williams*, M. £178,672.
[iii]Scottish Government (Scottish Enterprise). (2007-2008). A
standardised tool for the assessment of neurodevelopmental disorder.
Scottish Government (Scottish Enterprise). Williams, J.H.G., & Mon-Williams*,
[iv] BHRC Problem Solving Grant. (2012). Evaluating the
benefits of gamma knife surgery for patients with trigeminal neuralgia.
Pavitt*, S., Phillips*, N., & Mon-Williams*, M. £21,980.
[v] Medical Research Council Centenary Fellowship. (2012). The
effects of physical activity and motor coordination on child
development. £45,000. Hill*, L. (Mon-Williams*, M.
[vi] EPSRC Bridging the Gaps Fund. (2011). Haptic Enhancement
of Learning Processes. Mon-Williams*, M., Hewson*, R.,
Culmer*, P., & Clarke*. M. £28,145.
Note: All UoA4 researchers in bold; *research conducted by
academics at the UoL.
Details of the impact
Public policy and services
CKAT is the only available system that can provide an objective
assessment of manual control within classroom settings — as indexed by the
granting of a patent [A]. CKAT is impactful because it screens
manual motor control in large populations of children (in classroom
settings), with far more detail than previous assessment tools have
allowed, thereby facilitating objective identification of children with
difficulties for timely treatment/support. This innovation has, in terms
of public policy, resulted in a regulatory authority changing its
practices by adopting a new method (i.e. services) for screening
educational difficulties within school settings [B]. Children in
Bradford are now screened for motor deficits and provided with an
intervention if problems are detected. Specifically, since 2012 the City
of Bradford Metropolitan District Council's Education Department is
offering primary schools within its area the opportunity to participate in
the `Starting School' screening programme. This programme includes
assessing every participating child during their first year of school on
CKAT. Results of individual children's CKAT assessments are provided to
participating schools and teachers then use this information to guide
additional investigation and support children identified as being at risk
of motor deficit. The local educational authority view this initiative as
being of great benefit as CKAT is:
"...giving our teachers the ability to augment their professional
judgements with detailed objective assessments that allow them to make
properly informed judgements about how best to support their students.
Results are also aggregated and given to schools that work together in a
Local Area Partnerships (LAPs), helping us in our strategic planning as
well." Strategic Director, Children's Services, Bradford City
Practitioners and children's health & welfare
In 2012/13, 43 schools participated in the first year of the programme
(~2,500 children), with 88 schools (~4,000 children) committed for this
current year (i.e. 2012-13). This represents approximately 70% of the 125
schools in the city of Bradford. This widespread screening of children for
motor deficits has in turn affected practitioners, influencing practices
and the level of support provided in school for children with motor
difficulties. Evidence of impact comes from:
- Teachers receiving new training:
"In response to the CKAT assessments we have run Continuing
Professional Development (CPD) sessions for teachers to provide them
with information and ideas on what to do to help children with motor
learning difficulties in their classrooms...This has led to teachers
adopting certain lesson plans to include motor learning as an embedded
element within them...the assessments have raised awareness of the
importance of motor learning as a foundation for other aspects of
learning." Advisor, Bradford Schools Linking Network [C].
- Children identified as needing evaluation for a statement of special
" ... these assessments have confirmed teacher's professional
judgements and led to further more detailed assessments being conducted,
as we attempt to ascertain the specific challenges each child faces."
Advisor, Bradford Schools Linking Network [C].
- Schools providing additional in-school support to children identified
as having difficulties:
" ... assessments have also prompted us to seek innovative ways of
intervening to support motor-learning. For example, we are using school
resources to develop an after-school club designed to support children
with movement problems." Advisor, Bradford Schools Linking Network [C]
" ... provided clarity to teachers about the children who need
particularly focussed support. The value of having objective measures
like this to support teacher's professional judgement is considerable...
In certain cases, we have been able to put in place additional support
for those that need it most. In such instances the assessments have
guided us in how we tailor our support to the individual student's
needs." Head Teacher, Bradford Primary School [C].
In summary, Bradford Educational Services are using CKAT to identify
children with problems in order to provide additional support - i.e. the
Regulatory Authority has been convinced to change practice [B].
CKAT also has direct impact on health and welfare benefits for children,
enabling them to gain more timely and effective access to the support they
need. It increases the efficiency with which the referral system operates
in identifying children requiring additional support and treatment for
movement problems, ensuring their difficulties are mitigated as early as
"CKAT assessments have focussed our attention on an important issue
which can be overlooked in mainstream education (i.e. the development of
fine motor skills) and given us the detailed objective tools we need to
monitor motor skill development in our students and then act to have an
impact for the students that need it most." Advisor, Bradford
Schools Linking Network [C].
"These snapshots of children's initial ability levels provide us in
the Education sector with crucial early indicators of which children may
require additional support and in what specific areas...and help
identify at an early age which children might usefully benefit from
referral for additional support." Strategic Director, Children's
Services, Bradford City Council [B].
For these reasons, CKAT is being used in the US (Indiana) to identify
children with motor problems so they can receive robotic therapy for
handwriting problems. Research has shown that children with motor problems
can improve their performance with robot therapy and CKAT allows
identification of those children who benefit from this intervention [D].
Moreover, CKAT is being used as the clinical trial outcome measure within
a National Institutes of Health (NIH) $800,000 funded project [E]
investigating the efficacy of the robotic treatment and has been
implemented by clinicians at the University of California, Los Angeles
(UCLA), USA to measure post-surgical motor outcomes for people following
neural surgery. For example, the UCLA team has recently evaluated manual
dexterity before and after cervical spinal injection for pain in over 30
of their patients [F].
Impact on commerce
CKAT has been commercialised via a licensing agreement [G], which
the UoL and the University of Aberdeen signed with Mulraney Group in 2012.
Royalties are split based on Aberdeen's revenue-share model (Leeds is
entitled to a 39% share of overall royalties). This license demonstrates
commercial impact, as evidenced by job creation and revenue generation by
Mulraney Group in 2013:
"The Mulraney group have identified CKAT as a significant commercial
opportunity. The development of this system has generated jobs within
our company and enhanced our financial prospects. We anticipate further
job creation (FTE = 20) and an increased turnover of £3,000,000.
Moreover, the Mulraney Group believe that we are now in a position to
further capitalise on the investment..." Chief Executive, Mulraney
Sources to corroborate the impact
[A] Patent details: Mon-Williams, M., Williams, J.H.G.,
Plumb, M., & Wilson, A. `Apparatus and method for the assessment of
neurodevelopmental disorders'. (PCT/GB2007/001931). European Patent No.
07732951.4; USA Patent No. 12/302174. Retrieved from http://patentscope.wipo.int/search/en/WO2007135441
[B] Testimonial from the Strategic Director of Children's
Services, Bradford City Council (21.10.13).
[C] Testimonials from the Headteacher at Allerton Primary School,
Bradford and the School Curriculum Advisor who also acts as Advisor for
the Schools Linking Network (21.10.13).
[D] Testimonial from a child health expert based in the US
corroborating this statement (25.10.13).
[E] NIH documentation of grant with Mon-Williams as named
consultant providing CKAT expertise (14.1.13).
[F] UCLA testimonial corroborating the use of CKAT to measure
post-surgical motor outcomes (25.10.13).
[G] Legal document evidencing licensing agreement between the UoL
and Mulraney Group.
[H] Testimonial from the Chief Executive of Mulraney Group