neurologic development during infancy and childhood depends on physical health and genetic 
 disposition , and progresses under the influence of the social context and environment1 . to perform activities in daily life , motor 
 process and
motor development is based on actions 
 that a person enacts when interacting with and moving task objects and themselves around a 
 task environment2 , 3 . among environmental factors , home and family
parental education , socioeconomic status , family size , and 
 interaction with siblings are main elements of a child s close environment4 .
fine motor development affects other areas 
 of development , and in particular , school performance in later childhood . despite their 
 importance ,
age - appropriate fine motor abilities are seldom questionedor evaluated in 
 pediatric clinics : often , physicians ask parents or caregivers about the child s language 
 and gross motor abilities , and observe social and gross motor functions during physical 
 examination .
developmental screening tests , despite their high reliability and interest 
 agreement , are used only by 60% of u.s .
physicians , a rate likely to be lower in many other 
 countries5 , 6 . to interpret any observations or test results
, health professionals 
 should be familiar with normal development and influencing factors , and recognize the nature 
 and extent of external influences so that delays due to medical and treatable conditions are 
 not erroneously attributed to adverse environmental factors .
therefore , the aim of this 
 study was to investigate the effect of socioeconomic and maternal factors on the fine motor 
 development of healthy children .
data were obtained from 2,038 healthy children aged 082 months , 999 boys ( 49% ) and 1,039 
 girls ( 51% ) in four age groups : 024 months ( 57% ) , 2540 months ( 21.1% ) , 4156 months 
 ( 10.4% ) , and 5782 months ( 11.5% ) . children with a history of preterm delivery , birth weight 
 <
demographic data collected by using a standard questionnaire included the following :  mother s age : stratified as 20 , 2125 , 2630 , 3139 , and 40 years ;  mother s education : no education , up to 8 years schooling , 812 years schooling , and 12 
 years ;  number of children at home ;  area of residence within the district of ankara , indicating three different socioeconomic 
 groups ( seg ) as identified by the turkish institute of statistics : high , middle , and low 
 seg7 .
the developmental items commonly used in outpatient evaluation were retrieved from the 
 denver ii developmental screening test .
the denver ii version standardized for turkey was 
 applied by trained child development specialists or a pediatric neurologist .
the test 
 contains total 134 items in four developmental domains : personal - social , fine motor , 
 language , and gross motor .
inter tester and intra tester reliability were assessed by testers 
 watching video recordings of 20 children at 4 weeks interval and scoring separately , and 
 were > 90% throughout the data collection . only children with normal test results
were 
 included in this study , and the mean age at which they passed each fine motor item was 
 calculated .
this study was conducted by ihsan doramaci childrens hospital and the department of 
 pediatric neurology of hacettepe university , ankara , turkey .
ethical approval was obtained 
 from the ethics committee of hacettepe university faculty of medicine .
the effect of demographic and maternal factors on fine motor items was assessed for each 
 age group .
the results of tests were expressed as the number of observations ( n ) , mean ( x )  
 standard deviation ( sd ) .
homogeneity ( levene s ) and normality ( shapiro wilk ) tests were used 
 to choose statistical methods .
groups with normal distribution and homogeneous variances 
 were assessed by using pearson s correlation coefficient . as parametric test assumptions 
 were not available for some variables , these were assessed by using spearman rho correlation 
 coefficient .
the demographic characteristics of children are shown in table 1table 1.demographic characteristics of childrenn%age ( months)0241,13657.0254042021.1415620810.4578222911.5gendergirl1,03951.0boy99949.0number of children at home199948.8271334.8320510.04556.4minmaxxsdage ( months)0.38224.920.5height ( cm)5013584.120.5weight ( kg)1.630.811.95.5head circumference ( cm)345846.44.3 , and those of mothers in table 
 2table 2.demographic characteristics of mothersn%age ( years)<201075.3212549624.6263068333.8313964632.04086 4.3educationno education371.818 years72236.0812 years76438.1>12 years48324.1socioeconomic grouplow51925.9middle80640.2high65132.5minmaxxsdage ( years)165328.85.5 . the number of boys and girls were similar .
most children were from middle seg 
 and most mothers educational level was high school ( 812 years ) .
the factors affecting fine motor items were gender , mother s age and education , seg , and 
 number of siblings .
girls acted at earlier ages in grasping a rattle ( table 3table 3.factors affecting fine motor skills at 024 months of agefollows past midlinegrasps a rattlefollows 180reaches for objectslooks for ayarntransfers blocks from hand to handtakes two blocksbangs two blocks togetherplaces cube in a cupscribbles spontaneouslydumps raisin from bottle  demonstrateddumps raisin from bottle  spontaneousgenderr0.090 * 0.0020.0040.0010.0290.0200.1220.0400.0020.0500.0390.036mother s ager0.0490.0660.0800.0290.0690.0230.225 * 0.134 * 0.090 * 0.151 * 0.092 * 0.071mother s educationr0.0370.0870.0480.0490.0810.0180.0240.0820.0150.0680.0030.094*socioeconomic groupr0.217 * 0.187 * 0.153 * 0.181 * 0.093 * 0.117 * 0.1550.0700.139 * 0.0250.153 * 0.176*number of children at homer0.0010.0270.0080.0070.0580.0310.0580.0440.0170.0020.0370.017significant p values are in bold .
* p<0.05 ) , copying a circle ( table 
 4table 4.factors affecting fine motor skills at 2540 monthsoldcopies a circledraws a man of three partschild s genderr0.209 * 0.027mother s ager0.156 * 0.123*mother s educationr0.179 * 0.123*socioeconomic statusr0.137 * 0.070number of children at homer0.0560.120*significant p values are in bold . *
p<0.05 ) , copying a square ( table 
 5table 5.factors affecting fine motor skills at 4156 months oldcopies a circlecopies a crosscopies a squarecopies a square  demonstrateddraws a man of six partschild s genderr0.1310.1210.140 * 0.1220.240*mother s ager0.0430.0730.0680.0200.081mother s educationr0.0630.184 * 0.172 * 0.1330.105socioeconomic statusr0.206 * 0.226 * 0.1340.147 * 0.206*number of children at homer0.1360.0510.152 * 0.0840.102significant p values are in bold . * p<0.05table 6.factors affecting fine motor skills at 5782 months oldcopies circlecopies crosscopies squarecopies demonstrated squaredraws man and partschild s genderr0.0220.0100.0720.0190.231*mother s ager0.235 * 0.217 * 0.233 * 0.165 * 0.117mother s educationr0.200 * 0.334 * 0.350 * 0.309 * 0.309socioeconomic statusr0.0570.1260.0850.0380.232*number of children at homer0.1250.0340.0080.0120.054significant p values are in bold . * p<0.05 ) , and drawing a man of six parts ( tables 
 5 and 6 ) .
. * p<0.05 significant p values are in bold . * p<0.05 significant p values are in bold . * p<0.05 significant p values are in bold . * p<0.05 the mother s age was influential on several items in all age groups , most markedly in older 
 children ( > 57 months ) ( tables 36 ) . as the mother s age increased , the fine motor 
 skills of the children were acquired earlier . the mother s educational level was associated 
 with earlier acquisition of fine motor items , mostly in children older than 24 months ( tables 36 ) .
seg was positively correlated with fine motor skills before 56 months , most 
 markedly in the first 6 months of life ( tables 
 36 ) .
the number of children at home 
 was not effective ; however , it showed a negative correlation with one fine motor skill 
 between 41 and 56 months : copying a square ( table 
 5 ) .
fine motor functions carry great biological importance for humans , as reflected by the 
 large cortical representation of the hands in the cerebral cortex .
fine motor skills 
 correlate with cognitive test results , partly because of their part in psychometric testing 
 and partly because they allow the child to experiment and learn about the environment9 , 10 . 

on the other hand , they are less well recognized by parents who usually are more aware of 
 gross motor milestones and more often concerned with delays in gross motor skills11 .
factors likely to affect fine motor 
 skills must be known to plan interventions in children at a risk for delayed development . 

the present study analyzed fine motor development with respect to environmental factors in 
 the population , namely , mother s age and education , socioeconomic status , and number of 
 children in the household . the overall effect of gender was modest , with girls starting earlier in certain fine motor 
 skills of various ages .
similarly , nordberg et al.12 found that girls had higher scores in eye - hand coordination on 
 griffiths development scales at 4 years of age .
flatters et al.13 reported that girls were more likely to have superior 
 manual control in aiming and tracing tasks at school age .
other studies also showed girls 
 out performing boys on manual dexterity , especially in pencil- and paper - based skills14,15,16 .
it is plausible that fine motor 
 maturationis completed at a later age in boys .
the quality of the family environment has been associated with the intellectual and motor 
 development of the family members16 .
seg 
 affects the home environment , opportunities for educational and play activities , and 
 therefore gross and fine motor performance8 .
certain studies observed the influence of social class on a child s 
 development after 1 year17 and at 3 and 5 
 years of age18 , while others demonstrated 
 the effect of cultural factors , home environment , and seg on fine motor development in 
 9-month - old children and during the first 18 months of life10 , 19 .
children of low seg tend to show delays on 
 several motor development assessment batteries , although certain reports point to earlier 
 achievement of gross motor milestones than in children from higher seg20,21,22 .
perceptual - motor problems of children with lower 
 environmental resources may be related to poor nutrition , poor health care , or lack of 
 stimulation and opportunities for experience .
the effect of maternal education may involve higher intellectual level , positive 
 psychology , or higher income resulting in increased opportunities for the child .
jackson et 
 al.23 observed fewer behavioral 
 problems and improved preschool motor development in children of single - parent families with 
 higher maternal education .
higher social class and maternal education was found to be 
 related to psychomotor performance in children > 1 year of age17 , 23 and low 
 maternal education , after the age of 2 or 3 years24 , 
 25 .
our findings are consistent with 
 these studies : the positive effect of the mother s education was observed mostly in children 
 > 24 months of age .
the mother s age had a modest effect from late infancy through 
 childhood , which is less marked than the mother s education .
older siblings may serve as models for fine motor tasks and provide encouragement to their 
 younger siblings .
our 
 study did not show a considerable influence of the number of children at home : if at all , 
 the correlation with fine motor skills was negative .
 dilution of parental resources  or fewer 
 opportunities for the young child s fine motor experience26 . alvik27 also 
 demonstrated the presence of an older sibling to be associated with reduced scores in the 
 ages and stages questionnaire , a parent - completed screening instrument for children < 5.5 
 years old .
our study is based on items used in clinics for developmental screening because our aim was 
 to offer recommendations for pediatric outpatient and well - baby clinics caring for children 
 on a day - to - day basis .
fine motor problems are an important part of developmental 
 coordination disorder ( dcd ) , a term defining a neuromotor disability where motor 
 difficulties ( lower speed , lower accuracy ) interfere with daily life or school activities . 

motor control and muscle strength impairments are the primary reasons for motor behavior 
 disorders28 .
dcd affects about 5% of 
 school - age children29 . whether the 
 diagnosis of dcd can be predicted by screening for early fine motor skills , and whether the 
 severity of dcd may be reduced by means of intervention on influencing factors constitute 
 interesting areas to explore30.in 
 addition
, attention - deficit hyperactivity disorder ( adhd ) is a common neurodevelopmental 
 disorder that affects 37% of preschool and school - aged children .
it has been suggested that 
 the deficits of adhd children in memory performance , and the inability to allocate 
 sufficient attention to postural control may contribute to the trend of further 
 deteriorating fine motor skills with postural balance31 , 32 .
lee et al.33suggested that complex interactions between 
 multiple risk factors such as physical fitness levels of children are responsible for 
 adhd . in conclusion ,
sex and environmental and maternal factors appear influential in the 
 development of fine motor skills in early life .
these first years are a period of intense 
 biological maturation likely to shape the architecture of the central nervous system . 

negative environmental factors increase the developmental risk brought by adverse medical 
 conditions such as prematurity34 . on the 
 other hand
, those children at risk may benefit from reinforcement of positive factors : 
 interventions may overcome the effect of adverse perinatal events35 , 36 .
the findings 
 of our study may help the planning of interventions , such as providing additional preschool 
 education for children from disadvantaged economic and maternal education groups , and can 
 also contribute to the planning of research projects with matching intervention and control 
 groups .
 [ purpose ] the aim of this study was to investigate the influence of gender and family 
 factors on performance in the fine motor domain of the denver ii developmental screening 
 test . [ subjects and methods ] data were obtained from 2038 healthy children , 999 boys ( 49% ) 
 and 1039 girls ( 51% ) in four age groups : 024 months ( 57% ) , 2540 months ( 21.1% ) , 4156 
 months ( 10.4% ) , and 5782 months ( 11.5% ) . 
 [ results ] female gender , higher maternal age , 
 especially in children older than 24 months , and higher maternal education were associated 
 with earlier accomplishment of fine motor items . 
 higher socioeconomic status was 
 correlated with fine motor skills more noticeably at young ages . 
 [ conclusion ] the results 
 of this study support the role of environmental factors in the interpretation of fine 
 motor test results and point to target groups for intervention , such as infants in the low 
 socioeconomic group and preschool children of less educated mothers . 
 studies in different 
 populations may reveal particular patterns that affect child development . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION