Handwriting: current trends in occupational therapy practice

Preliminary Adaptation of Motor Tests to Evaluate Fine Motor Skills Associated with Mathematical Skills in Preschoolers

Mathematics is the subject in which many school-age children reveal difficulties. The literature has shown that fine motor skills, namely fine motor coordination and visuomotor integration, have been more robustly associated with mathematical performance. Studies have shown the importance that instruments have to evaluate these skills, however, the characteristics of these instruments do not fit the reality of kindergartens, they are usually time consuming and expensive and are usually administered by specialists. Thus, the main objective of this study was to identify, select, adapt and validate motor tests to evaluate fine motor skills associated with mathematical skills to allow the kindergarten teachers to apply them simultaneously to the class, with few material resources, in a short period of time and without the need for a lot of training to apply, score and classify. For this purpose, firstly, it was necessary to understand the main difficulties highlighted by kindergarten teachers regarding the use of instruments to evaluate fine motor skills and, thus, elaborate criteria to identify and select the tests that best fit the reality of kindergartens. The test identified, selected and adapted to evaluate fine motor coordination was threading beads from the Movement Evaluation Battery for Children, 2nd Edition. The main adaptation of the test was related to time, that is, instead of counting the time it takes the child to string the total number of cubes on the string, we counted the number of cubes the child strung on the string in a pre-defined time. To evaluate visual-motor integration, the test identified, selected and adapted was the Visual-Motor Integration (6th Edition) test. The main adaptation was related to material resources, that is, it will be possible to apply the test using only one sheet per child instead of the seven suggested by the original test. After the preliminary adaptation of the tests, their validation was performed by means of the degree of reliability (test-retest) and predictive validity. The results indicated that the adapted tests presented an excellent degree of reliability (>0.9) and could therefore be used to administer them simultaneously to the class group. The adapted Visual-Motor Integration test seems to be the most suitable one to be used by kindergarten teachers, in a classroom context, to simultaneously evaluate students' fine motor skills and associate their results with mathematical skills.

A Scoping Review of Grasp and Handwriting Performance in School-Age Children

OBJECTIVE

Handwriting is a critical functional skill that impacts academic participation and progress. Occupational therapists address components of grasp in their handwriting intervention as it is commonly assumed that grasp affects legibility, fluency, and endurance, yet research studies examining this relationship are limited.

METHOD

We used scoping review methodology to map existing research on grasp and handwriting performance in school-age children and to identify gaps in the literature.

RESULTS

Thirteen articles met search criteria and were categorized by grasp patterns and handwriting performance, and grasp force and handwriting performance. Findings suggest an inefficient grasp can lead to decreased handwriting legibility and fatigue. The current literature is inconclusive and several gaps were identified.

CONCLUSION

Additional studies should address research gaps through inclusion of children with special needs and interventions including lengthier handwriting tasks representative of a typical school day.

Psychometric Assessment of the Handwriting Proficiency Screening Questionnaire (HPSQ)-Thai Version for Primary School-Aged Children

In this study, the original Handwriting Proficiency Screening Questionnaire (HPSQ) was translated into Thai and cross-culturally adapted for use among school-aged children in Thailand. Additionally, the initial psychometric properties of the new Thai version were assessed, including internal consistency, construct validity, and content validity. The original HPSQ was forward-translated by two independent translators from English to Thai and then back-translated. A final consolidation was conducted by an expert committee to develop the Thai HPSQ. In the psychometric evaluation, content validity was quantified using the item-objective congruence (IOC) value for each item. Intra-rater and inter-rater reliabilities were also assessed. Internal consistency was measured using Cronbach’s alpha coefficient, and confirmatory factor analysis models were used to examine its construct validity. The Thai version of the HPSQ had excellent internal consistency (α = 0.92), good construct, and content validity (IOC value > 0.6). Intra-rater reliability was good (intraclass correlation coefficient (ICC) = 0.98), and inter-rater reliability ranged from fair to good (ICC = 0.46−0.77). Factor analysis revealed that a three-factor model best fitted the data. Thus, the Thai version of the HPSQ is a reliable and valid instrument for handwriting evaluation among Thai school-aged children. It can be useful for teachers and therapists to identify students with handwriting problems.

Handwriting and typing: Occupational therapy practice when supporting adolescents with handwriting difficulties

Introduction

While most children have developed effective handwriting by secondary school age, some have handwriting difficulties that hamper academic progress. Occupational therapists play a role in assessment and planning support, which may include introducing typing as an alternative. However, there is limited understanding regarding how decisions are made about recommending typing. This study explored the support provided to adolescents with handwriting difficulties by occupational therapists, and the contextual factors that influence their decision-making.

Method

Semi-structured interviews were conducted with 13 occupational therapists and analysed using thematic analysis.

Findings

Although there was shared practice underpinned by occupational therapy philosophy, there was also divergent practice due to different approaches. Roles and responsibilities, resources, and evidence and experience influenced occupational therapists’ practice. Understanding the adolescent’s motivation, the effect of handwriting difficulties on well-being and the need for a functional method to record schoolwork, was central to occupational therapists’ decision-making to recommend typing.

Conclusion

Strategies are needed to address the knowledge-practice gap, including evidence-based guidelines. Closer collaboration between occupational therapists and school staff could increase understanding of roles and highlight the unique occupational therapy contribution. Further research examining whether, when and how to introduce typing as an alternative to handwriting would support best practice.

The Development and Preliminary Psychometric Properties of the TeleWrite: A Telehealth-Based Handwriting Assessment for School-Aged Children

This article describes the development and preliminary psychometric properties of the TeleWrite, a handwriting assessment tool designed to measure the rate, accuracy, and fluency of children's handwriting for children in first through third grade administered via telehealth. A series of three pilot studies were completed to determine initial interrater reliability, content validity, and clinical utility of the TeleWrite. A study with eight children was used to determine preliminary interrater reliability testing using a beta version of the TeleWrite with (n = 9) raters. The reliability coefficient was obtained using intraclass correlation (ICC) and yielded α = 0.92 for total scores, CI [0.815, 0.983] and the Cronbach's α measure for internal consistency was α = 0.95 (excellent). A clinical utility survey of (n = 55) pediatric occupational therapists was used to obtain their clinical impression regarding the usefulness and accuracy. Representing twelve different countries and twenty-two U.S. states, the respondents indicated that 61% (n = 33) are quite or extremely likely to use the TeleWrite in their practice and most participants (64%; n = 35) indicated that TeleWrite was quite/extremely accurate in measuring handwriting performance. Third, a content validity study with nine handwriting experts reviewed and concluded that all ten subtests of the TeleWrite tool are considered essential. All preliminary studies strengthen the development of the TeleWrite assessment to advance to construct validation of the tool.

No evidence of a minimal clinically important difference for the Beery-Buktenica Developmental Test of Visual-Motor Integration in children with autism spectrum disorder

The Beery Visual-Motor Integration (VMI) battery of tests are some of the most commonly used assessments in pediatric occupational therapy, often used to measure change over time. However, the minimal clinically important difference (MCID) has not been estimated for interpreting change scores. We estimated the MCID for the Beery VMI battery of tests in children with autism spectrum disorder (ASD). Four occupational therapists collected data in a public elementary school on 64 children with ASD. The Beery VMI battery was administered to children with ASD twice, approximately 11 months apart. To estimate MCID values, Beery VMI battery scores were anchored to 15-point Likert questions measuring occupational therapists’ ratings of functional change over three domains: fine motor skills, handwriting, and activities of daily living (ADLs). Using this anchor-based method, we were unable to estimate MCID values for the Beery VMI battery. Children’s Beery VMI battery scores did not change significantly over the course of the school year, and there was only one weak correlation between VMI battery change scores and therapists’ ratings of change. The inability to estimate Beery VMI battery MCID values for children with ASD adds further support for research cautioning the use of the Beery VMI as an outcome measure.

Protracted Neural Development of Dorsal Motor Systems During Handwriting and the Relation to Early Literacy Skills

Handwriting is a complex visual-motor skill that affects early reading development. A large body of work has demonstrated that handwriting is supported by a widespread neural system comprising ventral-temporal, parietal, and frontal motor regions in adults. Recent work has demonstrated that this neural system is largely established by 8 years of age, suggesting that the development of this system occurs in young children who are still learning to read and write. We made use of a novel MRI-compatible writing tablet that allowed us to measure brain activation in 5-8-year-old children during handwriting. We compared activation during handwriting in children and adults to provide information concerning the developmental trajectory of the neural system that supports handwriting. We found that parietal and frontal motor involvement during handwriting in children is different from adults, suggesting that the neural system that supports handwriting changes over the course of development. Furthermore, we found that parietal and frontal motor activation correlated with a literacy composite score in our child sample, suggesting that the individual differences in the dorsal response during handwriting are related to individual differences in emerging literacy skills. Our results suggest that components of the widespread neural system supporting handwriting develop at different rates and provide insight into the mechanisms underlying the contributions of handwriting to early literacy development.

Self-determined Occupational Performance Model for Children From Economically Disadvantaged Backgrounds : Modèle de performance occupationnelle autodéterminée pour les enfants issus de milieux économiquement défavorisés

Background. Children from low-income backgrounds have a higher incidence of handwriting challenges due to the unique social and environmental stressors associated with poverty. Additionally, children from economically disadvantaged households are at risk for motor, cognitive, and social deficits, which further impact their handwriting performance. Purpose. The purpose of this paper is to propose a theoretical model that provides a holistic perspective for addressing the handwriting needs of children from low-socioeconomic backgrounds. Key Issues. The presented conceptual model is derived from the person-environment-occupation model for occupational performance and self-determination theory. These theories reciprocally complement and enhance each other, providing a foundation from which clinicians can guide evaluation and intervention. Implications. Through the use of the proposed model, evaluation and intervention focus on intrinsic motivation while considering the physical, social, and cultural impacts on a child's occupational performance. The provider connects with the child's basic psychological needs, thus improving handwriting outcomes and facilitating improved academic performance.

Haptic Guidance to Support Handwriting for Children With Cognitive and Fine Motor Delays

Handwriting is an essential skill for developing sensorimotor and intellectual skills in children. Handwriting constitutes a complex activity relying on cognitive, visual-motor, memory and linguistic abilities, and is therefore challenging to master, especially for children with learning difficulties such as those with cognitive, sensorimotor or memory deficits. Recently-emerged haptic guidance systems have a potential to facilitate the acquisition of handwriting skills in both adults and children. In this paper we present a longitudinal experimental study that examined the effects of haptic guidance to improve handwriting skills in children with cognitive and fine motor delays as a function of the handwriting complexity in terms of visual familiarity and haptic difficulty. A haptic-based handwriting training platform that provides haptic guidance along the trajectory of a handwriting task was utilized. 12 children with cognitive and fine motor delays defined in terms of intellectual difficulty (IQ score) and mild motor difficulty in pincer grasp control, participated in the study. Children were divided into two groups, a target group and a control group. The target group completed haptic-guided training and pencil-and-paper test whereas the control group took only the pencil-and-paper test without any training. A total of 32 handwriting tasks was used in the study where 16 tasks were used for training while the entire 32 tasks were completed for evaluation. Results demonstrated that the target group performed significantly better than the control group for handwriting tasks that are visually familiar but haptically difficult (Wilcoxon signed-rank test, p 0.01). An improvement was also seen in the performance of untrained tasks as well as trained tasks (Spearman's linear correlation coefficient, 0.667; p = 0.05). In addition to confirming that haptic guidance can significantly improve motor functions, this study revealed a significant effect of task difficulty (visual familiarity and haptic complexity) on the effectiveness of haptic guidance for handwriting skill acquisition for children with cognitive and fine motor delays.

Handwriting status among Iranian primary school students: a cross-sectional study

Background/Aims

Handwriting difficulties among school students are the primary reason for referral to school-based occupational therapy. Appropriate criteria and a complete view of the students' handwriting status are lacking in Iran. The purpose of this study was to gather comprehensive information about handwriting issues for therapists and related disciplines in Iran.

Methods

In this cross-sectional study, the handwriting status of 1262 Persian-language elementary school students (grades 2 and 3) from governmental schools was surveyed using the Persian handwriting assessment tool.

Results

There were statistically significant differences in handwriting components between second and third grade students except for word size and text slant. Handwriting components were different between boys and girls, and between right- and left-handed writers. Regression analysis revealed a positive relationships between age and grade and most of the handwriting components.

Conclusions

The results of this study have implications for teachers, therapists and other specialists who work and research on handwriting status of typically healthy students and students who are disabled in Iran. Handwriting skills improve over time and it seems that girls and right-handed writers are better writers regarding legibility.

The Persian Handwriting Assessment Tool for Primary School-Aged Children: Further Validation

Background

Handwriting problems are one of the common problems among students in the early years of education. The current study aimed to determine further validation aspects of the Persian Handwriting Assessment Tool (PHAT) in primary school-aged children.

Methods

The current methodological study was conducted on 452 healthy 8-10-year-old students in Tehran, Iran, selected via random cluster sampling method. Inclusion criteria were native Persian-speaking and no documented physical and mental impairments. Construct and structural validities were established by exploratory factor analysis (EFA) using principal axis factoring with Promax rotation and confirmatory factor analysis (CFA), respectively. Criterion validity was examined by expert opinion as the gold standard using Pearson correlation test. Internal consistency, test-retest, and inter-rater reliability were examined using Cronbach's alpha and intra-class correlation (ICC). Test-retest had a seven-day interval.

Results

The EFA results indicated two separate factors in the copying and dictation domains. Speed and orthographic error and size were considered as separate items. The CFA confirmed the factor structure. Criterion validity revealed low to moderate correlation (formation: 0.548, P<0.001; 0.503, P<0.001, spacing: 0.553, P<0.001; 0.307, P=0.030, alignment: 0.442, P<0.001; 0.358, P=0.011, size: -0.376, P=0.007; -0.445, P<0.001, and slant: 0.360, P=0.010; 0.372, P=0.008) in copying and dictation domain, respectively. Acceptable internal consistency (Cronbach's alpha: 0.72-0.99), excellent test-retest (ICC: 0.76-0.99), excellent inter-rater reliability between teachers (ICC: 0.86-0.95), and good to excellent inter-rater reliability between teachers and the occupational therapist (ICC: 0.60-0.95) were reported.

Conclusion

The results indicated that the PHAT was a valid and reliable tool for assessing handwriting in primary school-aged children.

Disorder of written expression and dysgraphia: definition, diagnosis, and management

Writing is a complex task that is vital to learning and is usually acquired in the early years of life. 'Dysgraphia' and 'specific learning disorder in written expression' are terms used to describe those individuals who, despite exposure to adequate instruction, demonstrate writing ability discordant with their cognitive level and age. Dysgraphia can present with different symptoms at different ages. Different theories have been proposed regarding the mechanisms of dysgraphia. Dysgraphia is poorly understood and is often undiagnosed. It has a high rate of co-morbidity with other learning and psychiatric disorders. The diagnosis and treatment of dysgraphia and specific learning disorders typically centers around the educational system; however, the pediatrician can play an important role in surveillance and evaluation of co-morbidity as well as provision of guidance and support.

Psychometric Properties of Screening Questionnaires for Children With Handwriting Issues

Dysgraphia (D) is a complex specific learning disorder with a prevalence of up to 30%, which is linked with handwriting issues. The factors recognized for assessing these issues are legibility and performance time. Two questionnaires, the Handwriting Proficiency Screening Questionnaire (HPSQ) for teachers and its modification for children (HPSQ-C), were established as quick and valid screening tools along with a third factor - emotional and physical well-being. Until now, in the Czechia, there has been no validated screening tool for D diagnosis. A study was conducted on a set of 294 children from 3rd and 4th year of primary school (132 girls/162 boys; M age 8.96 ± 0.73) and 21 teachers who spent most of their time with them. Confirmatory factor analysis based on the theoretical background showed poor fit for HPSQ [χ2(32) = 115.07, p < 0.001; comparative fit index (CFI) = 0.95; Tucker-Lewis index (TLI) = 0.93; root mean square error of approximation (RMSEA) = 0.09; standard root mean square residual (SRMR) = 0.05] and excellent fit for HPSQ-C [χ2(32) = 31.12, p = 0.51; CFI = 1.0; TLI = 1.0; RMSEA = 0.0; SRMR = 0.04]. For the HPSQ-C models, there were no differences between boys and girls [Δχ2(7) = 12.55, p = 0.08]. Values of McDonalds's ω indicate excellent (HPSQ, ω = 0.9) and acceptable (HPSQ-C, ω = 0.7) reliability. Boys were assessed as worse writers than girls based on the results of both questionnaires. The grades positively correlate with the total scores of both HPSQ (r = 0.54, p < 0.01) and HPSQ-C (r = 0.28, p < 0.01). Based on the results, for the assessment of handwriting difficulties experienced by Czech children, we recommend using the HPSQ-C questionnaire for research purposes.

A systematic review of occupational therapy intervention for handwriting skills in 4-6 year old children

INTRODUCTION

Handwriting skills play a significant role in all stages of an individual's life. Writing interventions should be considered at a younger age to ensure proper development of writing skills. Hence, the aims of this study is to evaluate the current evidence of occupational therapy interventions in handwriting skills for 4-6 year old children.

METHODS

Published literature was systematically searched according to PRISMA guidelines using specific key terms. Initial search identified 785 studies; however only seven met the inclusion criteria and were assessed for final review. Studies were methodologically appraised using the McMaster Critical Review Form-Quantitative Studies.

RESULTS

The review found no randomised control trial study design pertaining to the reviewed area. However, it can be seen that occupational therapy interventions for writing skills in 4-6 year old children managed to increase the targeted skills. The results were similar across samples with or without disabilities. An effective integration of occupational therapy interventions into educational curriculum was found to save both time and cost.

CONCLUSION

The long-term benefit from these interventions and the effects of these interventions on a broader spectrum of fine motor abilities need to be explored further with stronger research designs. However, the lack of studies adopting high level study designs, i.e., RCT designs means, results need to be approached with caution by occupational therapists when implementing handwriting skills intervention in practice.

Developmental coordination disorder and dysgraphia: signs and symptoms, diagnosis, and rehabilitation

Developmental coordination disorder (DCD) is a common and well-recognized neurodevelopmental disorder affecting approximately 5 in every 100 individuals worldwide. It has long been included in standard national and international classifications of disorders (especially the Diagnostic and Statistical Manual of Mental Disorders). Children and adults with DCD may come to medical or paramedical attention because of poor motor skills, poor motor coordination, and/or impaired procedural learning affecting activities of daily living. Studies show DCD persistence of 30-70% in adulthood for individuals who were diagnosed with DCD as children, with direct consequences in the academic realm and even beyond. In particular, individuals with DCD are at increased risk of impaired handwriting skills. Medium-term and long-term prognosis depends on the timing of the diagnosis, (possible) comorbid disorders (and their diagnosis), the variability of signs and symptoms (number and intensity), and the nature and frequency of the interventions individuals receive. We therefore chose to investigate the signs and symptoms, diagnosis, and rehabilitation of both DCD and developmental dysgraphia, which continues to receive far too little attention in its own right from researchers and clinicians.

Evaluation of the Reliability and Validity of the Brazilian Version of the Here’s How I Write:

OBJECTIVE. Our objective was to translate the Here’s How I Write: A Child’s Self-Assessment and Goal Setting Tool (HHIW) to Portuguese; adapt it to the Brazilian culture; and analyze its reliability, validity, and clinical feasibility.

METHOD. The study was developed in two steps: adaptation of the HHIW to Brazilian Portuguese, followed by experimental application to examine its validity and reliability. The participants were 60 children and their teachers, divided into two groups: Group 1, whose members had handwriting difficulties, and Group 2, whose members did not.

RESULTS. Children with poor handwriting scored lower on the HHIW for both self- and teacher report. Test–retest reliability of the children’s (.96) and teachers’ (.93) questionnaires as well as internal consistency (.91 and .95, respectively) were excellent. There was good agreement (.74) between the children’s and teachers’ total scores.

CONCLUSIONS. This study adds further evidence of validity and reliability and supports the international use of the HHIW. The HHIW is a useful resource to engage children and teachers in a collaborative relationship to improve handwriting.

Mental practice combined with repetitive task practice to rehabilitate handwriting in children

BACKGROUND.

Handwriting dysfunction contributes to 40% of all school-based referrals to occupational therapy. Empirically based handwriting interventions are needed to remediate the negative effects of handwriting dysfunction on a child's occupational performance.

PURPOSE.

This study examined the effectiveness of mental practice (MP) combined with repetitive task practice (RTP) to rehabilitate handwriting in children.

METHOD.

Twenty typically developing first and second graders with impaired handwriting received RTP twice a week for 4 weeks, then engaged in MP combined with RTP for the same duration. Using the Minnesota Handwriting Assessment (MHA), they were assessed across four time points: baseline (1), after RTP (2), after MP combined with RTP (3), and follow-up (4).

FINDINGS.

Children significantly improved and retained this increase on all variables of MHA ( p < .001) after MP combined with RTP. After RTP, the only significant improvement occurred in handwriting form ( p < .001).

IMPLICATIONS.

MP may be a potential therapeutic addition to RTP in rehabilitating global handwriting dysfunction.

Pressure distributions on the chair seat and backrest correlate with handwriting outcomes of school children

BACKGROUND

Postures while sitting are believed to have an important influence on the process of writing and quality of handwriting, but data in this field are sparse.

OBJECTIVES

The current study was undertaken to investigate correlations between 'ordinary' children's handwriting skills and their posture and stability while sitting.

METHODS

Twenty-nine children with typical development (age 9.2±0.8 years) underwent the Hebrew Handwriting Evaluation, while the pressure distributions on their seats and backrests were recorded using a pressure mapping system.

RESULTS

There was an increase in the odds of erasing and overwriting letters in dictation tasks when body displacements of the buttocks increased [Odds Ratio (OR) = 1.01, 95% CI 1.000-1.02, p = 0.050]. Children who did not lean on the backrest were more likely to have legible handwriting in copying tasks (OR = 0.136, 95% CI 0.026-0.723, p = 0.019).

CONCLUSIONS

The awareness and involvement of health practitioners in sitting postures of children at school might promote activities such as writing. Further investigation of movement patterns while writing and of the correlations of these patterns with handwriting outcomes is recommended. More research regarding adjustments at the school environment for children with developmental disorders is also warranted.

Examining Validity of the Print Tool Compared With Test of Handwriting Skills-Revised

Handwriting assessments offer practitioners an objective measure to determine handwriting deficits, track student progress, and provide evidence for the use of occupational therapy intervention. This study determines the concurrent validity of the Print Tool with the Test of Handwriting Skills-Revised (THS-R) and examines the alignment of teacher perception with the Print Tool. Participants included 46 first- and second-grade students. All participants completed both handwriting assessments, and classroom teachers (n = 4) rated each students' overall handwriting performance and potential areas of concern addressed by the Print Tool. The Print Tool overall scores have a strong correlation (r = .606) with THS-R standard scores, suggesting good concurrent validity. Median Print Tool overall scores increased with each successive teacher rating classification, supporting alignment with teacher perception. This study provides preliminary evidence for the use of the Print Tool by occupational therapy practitioners to identify potential handwriting deficits that also align with teacher perception of performance.

Development of the Handwriting Legibility Scale (HLS): A preliminary examination of Reliability and Validity

BACKGROUND

Demands for the production of legible handwriting produced in a timely manner increase as children progress through school. Despite the considerable number of children faced with handwriting difficulties, there is no quick and practical tool to assess legibility in this population.

AIM

The aim of this study was to develop the Handwriting Legibility Scale (HLS) and to establish the scale's reliability and validity.

METHODS

The HLS is a non-language dependent scale which assesses global legibility, based on five criteria applied to samples of 'free writing'. Content validity, inter-rater reliability and internal consistency were initially examined using scripts from 20 children aged 8-14 years. Construct validity was established by Principal Component Analysis (PCA) of data from 150 school children aged 9-14 years, with an additional examination of gender effects. Discriminant validity of the HLS score was examined in 29 children with Developmental Coordination Disorder (DCD) and 29 typically developing (TD) children.

RESULTS

The results indicated high internal consistency (α=0.92). The inter-rater reliability was acceptable but indicates the need to refine the scoring instructions. PCA of the five components revealed a one factor solution explaining 61% of the variance. In the discriminant analysis, 86.2% of the children with DCD and 89.7% of the TD children were correctly classified to their groups based on the total HLS score.

CONCLUSIONS

The overall findings suggest that the HLS may be a useful tool to identify poor handwriting legibility, with application across different languages and writing scripts.

Effectiveness of a self-regulated remedial program for handwriting difficulties

BACKGROUND

Handwriting difficulties may have pervasive effects on a child's school performance. I Can! is a remedial handwriting program with a focus on self-regulated learning and applying motor learning principles combined with a behavioural approach. It is developed for typically developing children with handwriting problems.

OBJECTIVE

The study aim was to evaluate the program's effectiveness.

MATERIALS AND METHODS

Thirty-one children aged 7-8 year participated in a cross-over study. Handwriting quality and speed were repeatedly assessed by means of the Systematic Screening of Handwriting Difficulties test. Difficulties addressed were fluency in letter formation, fluency in letter connections, letter height, regularity of letter height, space between words, and line path.

RESULTS

Mixed model analysis revealed improved quality of writing and speed for all children but significantly more improvement in handwriting quality for the children participating in the program. Although writing speed improved over time, no additional effects of the program occurred.

CONCLUSIONS AND SIGNIFICANCE

'I Can!' is found to be an effective instructive program to ameliorate handwriting quality in typically developing children with handwriting difficulties. The program's success was by a therapy burst of only 7 weeks focusing on the child's self-regulated learning capacities, within an individualized education plan according to their needs and goals.

Visual and Haptic Perception Training to Improve Handwriting Skills in Children With Dysgraphia

We investigated a visual-perceptual and haptic-perceptual training program to enhance motor skills and Chinese handwriting performance among children with handwriting difficulties. The participants were 28 first- and second-grade children with handwriting difficulties. They were matched according to age and then randomly assigned into a control group or an experimental group. Participants in the experimental group received 12 sessions of a training program, whereas those in the control group received conventional handwriting training. The Test of Visual Perceptual Skills-Third Edition (TVPS-3), Tactual Performance Test (TPT), and Battery of Chinese Basic Literacy (BCBL) were all administered before and after 6 wk of intervention. Repeated-measures analysis of variance revealed that the experimental group showed significant improvement on the TVPS-3 but not on the TPT. Along with the improved visual-perceptual skills, the experimental group showed a significant difference in far-point copy speed and handwriting accuracy, as reflected in the BCBL.

Motor-Free Visual Perception Test — Revised: An Overview and Critique

Paediatric occupational therapists often assess and treat school-age children and youth presenting with visual perceptual dysfunction. It is, therefore, important that occupational therapists use visual perceptual instruments that possess sound measurement properties (such as validity, reliability, responsiveness and clinical utility). The Motor-Free Visual Perception Test – Revised (MVPT-R) is an instrument frequently used by paediatric occupational therapists. Clinicians need to be cognisant of the measurement properties of the assessments they use in order to provide the best level of care for the paediatric clients they serve. Therefore, a review and critique of the MVPT-R is presented.

Even though the MVPT-R has been revised recently, little has been done to address issues related to its reliability and validity. Evidence of criterion-related validity and construct validity, in particular, is still lacking. The rationale for measuring motor-free visual perception is also not well developed and needs to be expanded in the MVPT-R manual. In addition, the issue of summing the scores from the five MVPT-R subscales is questionable. What the final MVPT-R summed score really measures in terms of a screening evaluation or diagnosis is also lacking. At this stage, this instrument should be used and interpreted by occupational therapists with caution.

Paediatric Occupational Therapy University Programme Curricula in the United Kingdom

The paediatric curriculum component of entry-level occupational therapy education programmes in the United Kingdom was examined and comparisons were made with the practice literature to determine if students were being taught current best practices.

Questionnaires were mailed electronically to the identified paediatric faculty members of the 27 universities with an entry-level occupational therapy education programme in the United Kingdom. Ten completed questionnaires were returned, giving a response rate of 37%.

The survey results indicated that paediatrics constituted less than 5% of the total curriculum content of the respondent university programmes. The theory, assessments and treatment approaches taught in the education programmes were similar to those used in clinical practice with children. Some gaps in what was taught to students were apparent, notably in the key paediatric area of visual perceptual dysfunction. The theory, assessments and intervention methods were not always taught as a cohesive stand-alone unit, so gaps occurred in the education programmes. This could lead to graduates using an eclectic approach or using personal conceptual frameworks based on postgraduate learning and work experience.

The association between measures of visual perception, visual-motor integration, and in-hand manipulation skills of school-age children and their manuscript handwriting speed

Introduction

The aim of this study was to investigate whether measures of visual perception, visual-motor integration, and in-hand manipulation skills of school-age children were associated with their manuscript handwriting speed.

Method

A convenience sample of 39 typically developing Australian students aged six to eight years completed the Beery–Buktenica Developmental Test of Visual-Motor Integration – 6th edition (DTVMI), the Developmental Test of Visual Perception – 3rd edition (DTVP-3), the Test of In-Hand Manipulation – Revised (TIHM-R), and the Handwriting Speed Test (HST). Spearman rho correlations and multi-linear regression analyses were completed to analyze the data.

Results

Significant correlations were found between visual perception, visual-motor integration, and in-hand manipulation skills and total letters written and total letters per minute. Regression analyses indicated that, when modeled together, the DTVP-3 eye–hand coordination and visual closure subscales and the TIHM-R were significant predictors of total letters written accounting for 25.5% of the variance. The DTVP-3 copying and visual closure subscales and the TIHM-R were predictive of total letters written per minute, with the TIHM-R making a significant unique contribution of 9.1% to the total variance of 26%.

Conclusion

Visual perception abilities, specifically visual closure skills, plus in-hand manipulation skills appear to be significant predictors of children’s printing speed and need to be assessed and potentially targeted for skill remediation when working with school-age children who present with manuscript handwriting difficulties.

Hand Strength, Handwriting, and Functional Skills in Children With Autism

OBJECTIVE. To establish hand strength development trends in children with autism and to investigate correlations between grip and pinch strength, components of handwriting, and functional activities in children with and without autism.

METHOD. Fifty-one children were divided into two groups: typically developing children and children on the autism spectrum. Each child completed testing for pinch and grip strength, handwriting legibility, pencil control, and independence in functional activities.

RESULTS. The children with autism followed the same strength development trends as the typically developing children. Grip strength correlated with pencil control in both groups and with handwriting legibility in the typically developing children but not in the children with autism. Grip and pinch strength correlated with independence with functional activities in both groups.

CONCLUSION. This study provides evidence that grip and pinch strength are important components in developing pencil control, handwriting legibility, and independence with functional fine motor tasks.

Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery-VMI): lessons from exploration of cultural variations in visual-motor integration performance of preschoolers

BACKGROUND

Visual-motor integration (VMI) is important in children's development because it is associated with the performance of many functional skills. Deficits in VMI have been linked to difficulties in academic performance and functional tasks. Clinical assessment experience of occupational therapists in Singapore suggested that there is a potential difference between the VMI performance of Singaporean and American children. Cross-cultural studies also implied that culture has an influence on a child's VMI performance, as it shapes the activities that a child participates in. The purpose of this study was to (1) explore if there was a difference between the VMI performance of Singaporean and American preschoolers, and (2) determine if there were ethnic differences in the VMI performance of Singaporean preschoolers.

METHODS

The Beery-VMI, which was standardized in America, is commonly used by occupational therapists in Singapore to assess the VMI ability of children. We administered the Beery-VMI (fifth edition) full form test (excluding the supplemental tests) to 385 preschoolers (mean age = 63.3 months) from randomly selected schools in Singapore. We compared the scores of Singaporean preschoolers with those of the American standardization norms using the one-sample t-test. Scores of different ethnic groups among the Singapore population were also compared using a one-way anova, followed by the Bonferroni post-hoc test.

RESULTS

Singaporean preschoolers and the standardization sample of American children performed significantly differently in all age groups (P < 0.05). Among the Singapore population, the scores were also significantly different (P < 0.05) between the (i) Chinese and Malay and (ii) Chinese and Indians ethnic groups.

CONCLUSION

Preschoolers from different cultural and ethnic groups had different VMI performance. Certain cultural beliefs and practices may affect VMI performance. Clinicians should exercise caution when using an assessment in communities and cultures outside the ones on which it was standardized.

The effect of computer-assisted therapeutic practice for children with handwriting deficit: a comparison with the effect of the traditional sensorimotor approach

The objective of this study was to compare the effect of computer-assisted practice with the sensorimotor approach on the remediation of handwriting problems in children with dysgraphia. In a randomized controlled trial, experiments were conducted to verify the intervention effect. Forty two children with handwriting deficit were assigned to computer-assisted instruction, sensorimotor training, or a control group. Handwriting performance was measured using the elementary reading/writing test and computerized handwriting evaluation before and after 6 weeks of intervention. Repeated-measures ANOVA of changed scores were conducted to show whether statistically significant differences across the three groups were present. Significant differences in the elementary reading/writing test were found among the three groups. The computer group showed more significant improvements than the other two groups did. In the kinematic and kinetic analyses, the computer group showed promising results in the remediation of handwriting speed and fluency. This study provided clinical evidence for applying a computer-assisted handwriting program for children with dysgraphia. Clinicians and school teachers are provided with a systematic intervention for the improvement of handwriting difficulties.

An examination of the effectiveness of Handwriting Without Tears® instruction

Background.

Handwriting is an important childhood occupation, and implications of poor handwriting may have significant long-term effects.

Purpose.

The purpose of this study was to determine the effectiveness of Handwriting Without Tears® (HWT) on Grade 1 students’ handwriting and perception of skills.

Methods.

A cross-over design was used. Repeated measures, at three points, included the Minnesota Handwriting Assessment (MHA) and performance rating scales.

Findings.

Eighty-three boys and 66 girls with an average age of 6.2 years participated in the study. Students receiving HWT achieved significantly higher improvements compared to students with teacher-designed instruction in MHA Total Test Score and in MHA components of form, size, space, and alignment (all p < .05). Students had higher average performance ratings when receiving HWT in the first half of the school year.

Implications.

Instruction using HWT improves students’ perception and skill in handwriting performance.

Effectiveness of a co-taught handwriting program for first grade students

Our study examined the effects of Write Start, a classroom-embedded handwriting/writing program on handwriting and writing fluency for first grade students, co-taught by occupational therapists and teachers. Two first grade classrooms received the Write Start and two received standard handwriting instruction. This co-taught program included specific feedback during handwriting practice, small group activities, student self-evaluation, and peer supports. The students were evaluated on handwriting legibility, fluency, and written expression at baseline, immediately after the program, and 6 months later. When performance was compared between the two groups, the students in the Write Start program improved significantly more in legibility (d = .57) and fluency (d = .75) than students who received standard instruction. Gains in handwriting speed (d = .18), average legibility (d = .26), and written expression (d = .25) did not differ significantly between the two groups. A co-taught, inclusive handwriting/writing program can promote first grade students' achievement of lower case legibility and writing fluency.

Signal-to-noise velocity peaks difference: a new method for evaluating the handwriting movement fluency in children with dysgraphia

This study evaluated handwriting movement dysfluency related to dysgraphia. A new variable, the Signal-to-Noise velocity peaks difference (SNvpd), was proposed to describe abnormal velocity fluctuations in cursive handwriting. This variable was compared to two variables most frequently used variables for assessing handwriting fluency. This comparison was carried out for three different groups, children with dysgraphia, proficient children, and adults, all of whom wrote the same single word. The adults were taken as the reference. Results revealed that, of the three variables studied, the SNvpd proved most efficient in discriminating children with dysgraphia, and that furthermore, it had the significant advantage of facilitating the localization of dysfluency peaks within a word. Our results also showed that the movement dysfluency of children with dysgraphia was specific to certain letters. In light of these results, we discuss the methodological and theoretical relevance of this new variable to the analysis of handwriting movement with the aim of characterizing dysgraphia.

A profile of canadian pediatric occupational therapy practice

PURPOSE

This study established a current profile of Canadian pediatric occupational therapy practice in terms of theories/practice models, assessments, and interventions.

METHOD

Respondents were 272 members of the Canadian Association of Occupational Therapists who indicated that pediatrics was their primary area of clinical practice. A purpose-designed survey was mailed to participants.

RESULTS

The response rate was adequate at 27.2% (n = 272/1,000). The primary client groups seen by pediatric therapists were developmental delay, learning disability, neurology, and those requiring rehabilitation. Sensory Integration and Client-Centred Practice were the most frequently utilized theories/practice models. The most commonly used assessments were the Developmental Test of Visual Motor Integration, Peabody Developmental Motor Scales, Bruininks-Oseretsky Test of Motor Proficiency, and the Sensory Profile. The most frequently used intervention techniques with pediatric clients were the instruction of parents/caregivers and children; assistive devices, adaptive equipment, and technology; activities of daily living/self-care skills; and environmental modification/access/structuring/adaptation.

CONCLUSIONS

Pediatric occupational therapists mainly used theories/ practice models that focused on three areas: Client-Centred practice, practice-oriented theories, and several theories/practice models based on occupation. Interventions focused on teaching, activities unique to occupational therapy, and on the functional needs of the client.

Assessing handwriting intervention effectiveness in elementary school students: a two-group controlled study

This study examined the effectiveness of two approaches used in elementary schools to improve children's handwriting. Participants were 72 New York City public school students from the first and second grades. A nonequivalent pretest-posttest group design was used in which students engaged in handwriting activities using two approaches: intensive handwriting practice and visual-perceptual-motor activities. Handwriting speed, legibility, and visual-motor skills were examined after a 12-wk Handwriting Club using multivariate analysis of variance. The results showed that students in the intensive handwriting practice group demonstrated significant improvements in handwriting legibility compared with students in the visual-perceptual-motor activity group. No significant effects in handwriting speed and visual-motor skills were found between the students in intensive handwriting practice group and the students in visual-perceptual-motor activities group. The Handwriting Club model is a natural intervention that fits easily into existing school curriculums and can be an effective short-term intervention (response to intervention Tier II).

Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children

OBJECTIVE. Pencil grasps other than the dynamic tripod may be functional for handwriting. This study examined the impact of grasp on handwriting speed and legibility.

METHOD. We videotaped 120 typically developing fourth-grade students while they performed a writing task. We categorized the grasps they used and evaluated their writing for speed and legibility using a handwriting assessment. Using linear regression analysis, we examined the relationship between grasp and handwriting.

RESULTS. We documented six categories of pencil grasp: four mature grasp patterns, one immature grasp pattern, and one alternating grasp pattern. Multiple linear regression results revealed no significant effect for mature grasp on either legibility or speed.

CONCLUSION. Pencil grasp patterns did not influence handwriting speed or legibility in this sample of typically developing children. This finding adds to the mounting body of evidence that alternative grasps may be acceptable for fast and legible handwriting.

Handwriting difficulties in children with autism spectrum disorders: a scoping review

Functional handwriting involves complex interactions among physical, cognitive and sensory systems. Impairments in many aspects of these systems are associated with Autism spectrum disorders (ASD), suggesting a heightened risk of handwriting difficulties in children with ASD. This scoping review aimed to: (1) survey the existing evidence about potential contributions to compromised handwriting function in children with ASD, and (2) map out the existing studies documenting handwriting difficulties in children with ASD. The current evidence implicates impairments in fine motor control and visual-motor integration as likely contributors to handwriting difficulties in children with ASD, though the role of the latter is not well-understood. Moreover, diminished overall legibility and compromised letter formation are emerging points of convergence among existing studies of handwriting quality in children with ASD.

Validating the use of the evaluation tool of children's handwriting-manuscript to identify handwriting difficulties and detect change in school-age children

In this study we sought to validate the discriminant ability of the Evaluation Tool of Children's Handwriting-Manuscript in identifying children in Grades 2-3 with handwriting difficulties and to determine the percentage of change in handwriting scores that is consistently detected by occupational therapists. Thirty-four therapists judged and compared 35 pairs of handwriting samples. Receiver operating characteristic (ROC) analyses were performed to determine (1) the optimal cutoff values for word and letter legibility scores that identify children with handwriting difficulties who should be seen in rehabilitation and (2) the minimal clinically important difference (MCID) in handwriting scores. Cutoff scores of 75.0% for total word legibility and 76.0% for total letter legibility were found to provide excellent levels of accuracy. A difference of 10.0%-12.5% for total word legibility and 6.0%-7.0% for total letter legibility were found as the MCID. Study findings enable therapists to quantitatively support clinical judgment when evaluating handwriting.

Effect of a coteaching handwriting program for first graders: one-group pretest-posttest design

We examined the effects of a cotaught handwriting and writing program on first-grade students grouped by low, average, and high baseline legibility. The program's aim was to increase legibility, handwriting speed, writing fluency, and written expression in students with diverse learning needs. Thirty-six first-grade students in two classrooms participated in a 12-wk handwriting and writing program cotaught by teachers and an occupational therapist. Students were assessed at pretest, posttest, and 6-mo follow-up using the Evaluation Tool of Children's Handwriting-Manuscript (ETCH-M) and the Woodcock-Johnson Writing Fluency and Writing Samples tests. Students made large gains in ETCH-M legibility (η² = .74), speed (η²s = .52-.65), Writing Fluency (η² = .58), and Writing Samples (η² = .59). Students with initially low legibility improved most in legibility; progress on the other tests was similar across low-, average-, and high-performing groups. This program appeared to benefit first-grade students with diverse learning needs and to increase handwriting legibility and speed and writing fluency.