Reliability, validity, and measurement invariance of a Chinese handwriting legibility scale among primary students in central China

Background

Chinese handwriting has a close relationship with spatial cognition, and the legibility dimension is prominent with its spatial-oriented characteristics. However, handwriting evaluation focusing on the detailed spatial aspects of the legibility dimension in the Chinese context is rare.

Aims and methods

We aimed to develop a Chinese Handwriting Legibility Scale (CHLS) and examine its reliability, validity, and measurement invariance among Chinese primary students of different grades. A total of 684 students aged 8-12 years were recruited from a mainstream primary school in central China and were asked to copy a Chinese template as legibly as possible within 4 min. The developed CHLS was used to assess these students' legibility performance.

Results

The seven-criteria CHLS favored content validity. The inter-rater reliability was good; however, the scoring instructions need to be refined. Principal component analysis (PCA) revealed a one-factor solution explaining 62.336% of the variance of the seven-criteria CHLS, and confirmatory factor analysis (CFA) confirmed its appropriateness. There was a high internal consistency (α = 0.902). In terms of measurement invariance, the factor structures and loadings of the CHLS were consistent across students of different grades; however, significant intercept variations were detected between students of Grades 2 and 4.

Conclusion

CHLS may be effective for evaluating Chinese handwriting legibility performance in the Chinese primary school context in the central region. Students' Chinese handwriting legibility performance may have developmental specificity in different grades.

Concurrent and Predictive Validity of a Cycloid Loops Copy Task to Assess Handwriting Disorders in Children

Handwriting disorders (HDs) are mainly assessed using script or cursive handwriting tasks. The most common is the scale for children's handwriting, with a French adaptation (BHK). The present study aims to assess the concurrent validity of a pre-scriptural task (copying a line of cycloid loops) with the BHK for the diagnosis of HDs. Thirty-five primary school children (7 females, 28 males) with HD aged 6-11 years were recruited and compared to 331 typically developing children (TDC). Spatial/temporal/kinematic measures were collected using a digital pen on a paper. Posture and inter-segmental writing arm coordination were video recorded. A logistic regression statistical method, including a receiver-operating characteristic curve, was used to assess the ability of the task to predict HD. Gestural patterns were significantly less mature in HDs than in TDC (p < 0.05), and associated with poorer quality, less fluid, and slower drawing (p < 0.001). Moreover, good correlations between temporal and kinematic measures and the BHK scale were found. Number of strokes, total drawing time, in-air pauses times, and number of velocity peaks showed very good sensitivity (88%) and specificity (74%) to diagnose HDs. Consequently, the cycloid loops task is an easy, robust, and predictive tool for clinicians to identify HDs before the alphabet is mastered.

Comparative Analysis of Cognitive, Motor, and Visual-Motor Functions in Pediatric Acute Lymphoblastic Leukemia Survivors With and Without Allogeneic Hematopoietic Stem Cell Transplantation

OBJECTIVE

Hematopoietic stem cell transplantation (HSCT) is an effective treatment for pediatric high-risk acute lymphoblastic leukemia (ALL) survivors. Still, both the disease and treatment often impair cognitive and motor functions, and HSCT is a risk factor for long-term deficits. The study aimed at investigating the effect of HSCT on cognitive, motor, and visual-motor functions. Two groups were enrolled: The first group received HSCT treatment, and the second group did not.

METHOD

Sixty-five ALL survivors participated in the study (ages: 7-17). Twenty-one of participants who underwent HSCT comprised the first group. We implemented tests from Cambridge Neuropsychological Test Automated Battery, Wechsler Intelligence Scale for Children, and Test of Memory and Learning to estimate cognitive functions, Bruininks-Oseretsky Test of Motor Proficiency to estimate motor functions, and Beery-Buktenica Developmental Test to estimate visual perceptual and visual motor functions. As independent variables for analysis we chose group (HSCT+/-), age at diagnosis, and current age.

RESULTS

MANCOVA test demonstrated significant effect of current age on cognitive functions (partial η2 = 0.55) and significant effect of HSCT treatment on motor functions (partial η2 = 0.19). Current age also had moderate effect on visual-motor functions (partial η2 = 0.11). Significant differences were found in most cognitive, motor, and visual-motor tests' results between the two groups, with HSCT+ group demonstrating poorer performance.

CONCLUSIONS

This study has several limitations, including small sample size, potentially mismatched groups, imbalanced gender ratio. Still, the findings underline the importance of considering late effects of HSCT, and age when designing rehabilitation programs.

Child-level factors affecting rate of learning to write in first grade

BACKGROUND

Written composition requires handwriting, spelling, and text planning skills, all largely learned through school instruction. Students' rate of learning to compose text in their first months at school will depend, in part, on their literacy-related abilities at school start. These effects have not previously been explored.

AIM

We aimed to establish the effects of various literacy-related abilities on the learning trajectory of first-grade students as they are taught to write.

SAMPLE

179 Spanish first-grade students (94 female, mean age 6.1 years) writing 3,512 texts.

METHOD

Students were assessed at start of school for spelling, transcription fluency, letter knowledge, phonological awareness, handwriting accuracy, word reading, and non-verbal reasoning. They were then taught under a curriculum that included researcher-designed instruction in handwriting, spelling, and ideation. Students' composition performance was probed at very regular intervals over their first 13 weeks at school.

RESULTS

Controlling for age, overall performance was predicted by spelling, transcription fluency, handwriting accuracy, word reading, and non-verbal reasoning. Most students showed rapid initial improvement, but then much slower learning. Weak spellers (and to a lesser extent less fluent hand-writers) showed weaker initial performance, but then steady improvement across the study period.

CONCLUSION

Transcription ability at school entry affects response to writing instruction.

Impact of Psycho-Educational Activities on Visual-Motor Integration, Fine Motor Skills and Name Writing among First Graders: A Kinematic Pilot Study

This pilot study presents the effects on acquisition of pre-writing skills of educational activities targeting visual-motor integration and fine motor skills on a convenient sample of first graders. After a 10-week intervention program, visual perceptual skills and fine motor control were tested on 13 six-year-old aged children. Participants completed the Beery-Buktenica VMI and the manual dexterity scale of the Movement ABC-2 at baseline (T1), after the intervention program (T2), and one month after the end of the educational activities (T3). Children's writing pressure, frequency, and automaticity were measured using a digitizer during the administration of name writing test at T1, T2, and T3. The purpose of the study was to investigate changes in visual-perceptual abilities and fine motor skills after the intervention program and examine correlational effects on children's kinematic writing performances. Findings reveal that educational activities impacted positively on children's visual motor coordination component of writing improving VMI scores. No statistically significant difference was detected across the three time points on students' manual dexterity skills. Measurement of writing kinematics allows to report and document variations in children's writing during intervention. This pilot study discusses these findings and their implications for the field on early childhood acquisition of foundational skills for handwriting. It also proposes potential topics for future research on this field.

Who Benefits from An Intervention Program on Foundational Skills for Handwriting Addressed to Kindergarten Children and First Graders?

This study examined the effectiveness of a 10-wk intervention program based on occupational therapy principles on visual-motor integration skills and fine motor abilities in kindergartners and first graders. We recruited 55 students tested three times with the Visual-Motor Integration Test (VMI) and Movement Assessment Battery for Children-2 (MABC-2): before the intervention (T1), post-intervention (T2) and one month later (T3). Research findings: Significant improvements were found on VMI between T1 and T2, particularly for kindergartners. Neither group of children demonstrated changes on manual dexterity scores. The present study showed that the intervention program led to different changes in the at-risk of motor impairment group than in the not at-risk children. Results indicated that games and stimulation activities helped children below the 16th percentile over time in the manual dexterity domain. A gender effect was observed, with female children increasing their abilities over time more than male peers. Future research should concentrate on stimulating fine motor skills in hand manipulation and test how these abilities influence graphomotor skills and handwriting over time. Finally, more research is needed to determine the impact of activities and games carried out in educational settings.

High Prevalence of Dysgraphia in Elementary Through High School Students With ADHD and Autism

OBJECTIVE

Prevalence of dysgraphia by age across all grade levels was determined in students with ADHD or autism.

METHOD

Referred children with normal intelligence and ADHD-Combined, ADHD-Inattentive, or autism ( N = 1,034) were administered the Developmental Test of Visual-Motor Integration (VMI) and Wechsler Intelligence Scale for Children (WISC).

RESULTS

VMI and WISC Coding scores were significantly lower than IQ and the normal mean of 100 for all diagnoses. More than half (59%) had dysgraphia, and 92% had a weakness in graphomotor ability relative to other abilities. Dysgraphia prevalence did not differ between diagnostic or age groups (6-7 years, 56%; 8-10 years, 60%; and 11-16 years, 61%).

CONCLUSION

Dysgraphia is common at all ages in children and adolescents with ADHD and autism. Accommodations and strategies for addressing this problem are discussed.

Motor function in survivors of pediatric acute lymphoblastic leukemia treated with chemotherapy-only

BACKGROUND

Up to 43% of survivors of pediatric acute lymphoblastic leukemia (ALL) may exhibit fine-motor problems. Information on manual dexterity in this cohort is still limited.

OBJECTIVES

We tested survivors of childhood ALL treated with chemotherapy-only for fine-motor function in terms of drawing and handwriting abilities using a Digitizing Tablet (DT) with three tasks for drawing and handwriting of varying complexity, for ataxia using the International Cooperative Ataxia Rating Scale (ICARS), and for tremor and hand-eye coordination using the Nine Hole Steadiness Tester (NHST).

RESULTS

We examined a cohort of non-irradiated survivors (n = 31) after a median time of 3.5 years after end of therapy. In all tasks of the DT the cohort demonstrated significant (p < 0.05) impairment of speed, automation, and variability in at least two tasks and significantly more pressure. Impaired speed (SPV) inversely correlated with lag time since end of therapy. Dexterity performance of six survivors (19%) lay below the 5th percentile. No survivor exhibited ataxia, tremor, or impaired hand-steadiness.

CONCLUSION

Despite the absence of gross ataxia, tremor, and impaired hand-eye coordination, we nevertheless detected significant fine-motor impairment in a relevant number of survivors of childhood ALL. Prospective studies are needed to reveal the pathophysiological underpinnings and genetic risk factors for development of such deficits due to ALL and its treatment.

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.

An Analysis of the Brain Systems Involved with Producing Letters by Hand

Complex visual-motor behaviors dominate human-environment interactions. Letter production, writing individual letters by hand, is an example of a complex visual-motor behavior composed of numerous behavioral components, including the required motor movements and the percepts that those motor movements create. By manipulating and isolating components of letter production, we provide experimental evidence that this complex visual-motor behavior is supported by a widespread neural system that is composed of smaller subsystems related to different sensorimotor components. Adult participants hand-printed letters with and without "ink" on an MR-safe digital writing tablet, perceived static and dynamic representations of their own handwritten letters, and perceived typeface letters during fMRI scanning. Our results can be summarized by three main findings: (1) Frontoparietal systems were associated with the motor component of letter production, whereas temporo-parietal systems were more associated with the visual component. (2) The more anterior regions of the left intraparietal sulcus were more associated with the motor component, whereas the more posterior regions were more associated with the visual component, with an area of visual-motor overlap in the posterior intraparietal sulcus. (3) The left posterior intraparietal sulcus and right fusiform gyrus responded similarly to both visual and motor components, and both regions also responded more during the perception of one's own handwritten letters compared with perceiving typed letters. These findings suggest that the neural systems recruited during complex visual-motor behaviors are composed of a set of interrelated sensorimotor subsystems that support the full behavior in different ways and, furthermore, that some of these subsystems can be rerecruited during passive perception in the absence of the full visual-motor behavior.

Chinese handwriting performance in preterm children in grade 2

Background

First graders born prematurely perform poorly on handwriting speed and legibility. However, whether there are specific legibility factors in which preterm children demonstrate difficulty remains unknown. In addition, handwriting performance beyond the first grade and the influence of sex on handwriting performance in preterm children are still unclear. We aimed to investigate the influence of prematurity and sex on multiple dimensions of handwriting in grade two and to identify the contributors to performance.

Methods

Sixty-three preterm (34 boys and 29 girls) and 67 full-term (27 boys and 40 girls) peers in grade two were included. Class teachers were asked to complete the Chinese Handwriting Evaluation Form. A subgroup of 39 preterm children received assessments on intelligence, visual perception, tactile and kinesthetic sensation, and fine motor skills. Their inattention behavior was rated using a maternal self-report with a behavioral scale.

Results

Boys born prematurely exhibited poorer performance in the speed dimension than full-term boys (p = 0.008), whereas there was comparable performance in the two groups of girls (p = 0.221). In the dimensions related to legibility, preterm boys (32.4%) had a higher percentage of children with difficulty in the construction dimension than the other groups (preterm girls: 6.9%, full-term boys: 7.4%, full-term girls: 5.0%). However, no group difference was found in the dimensions of accuracy and directionality. Of the sensory-perceptual-motor factors, attention was the most significant predictor of accuracy in performance (p = 0.046) and speed dimensions (p = 0.001) in preterm children.

Conclusions

Boys appear to be vulnerable to the adverse impacts of preterm birth in terms of performance in the dimensions of speed and construction in grade two. Based on the significant contribution of attention to handwriting performance in preterm children, assessment and intervention in the area of attention is strongly suggested for preterm children with handwriting problems.

The effect of fine motor skills on handwriting legibility in preschool age children

[Purpose] The purpose of this study was to examine the effect that fine motor skills have on handwriting legibility in children of preschool age. [Subjects and Methods] The subjects of this study were 52 children of normal growth and development. In order to ascertain handwriting legibility, a Korean alphabet writing assessment was used; to measure fine motor skills, fine motor precision and manual dexterity, sub-items of BOT-2 were measured. Furthermore, in order to measure in-hand manipulation skills, a Functional Dexterity Test was conducted. [Results] The results of the study showed a high level of correlation between fine motor skills and handwriting legibility. The study revealed that the accuracy of hand and in-hand manipulation skills is factors that have an effect on handwriting legibility. [Conclusion] Through the current research, occupational therapists can provide activities that aid the development of fine motor precision and in-hand manipulation skills for children during the instruction and treatment of handwriting to preschool age children, which helps to conduct better legibility in their handwriting.

Impact of handwriting training on fluency, spelling and text quality among third graders

As recent studies and theoretical assumptions suggest that the quality of texts composed by children and adolescents is affected by their transcription skills, this experimental field trial aims at investigating the impact of combined handwriting/spelling training on fluency, spelling and text quality among normally developing 3rd graders (N = 175). In addition to the combined handwriting/spelling training group, the sample includes two other intervention groups, a handwriting training group and a spelling training group as well as a reading fluency training control group. The participating teachers (N = 11) and their students were randomly assigned to the different intervention and control conditions, which were scheduled to last 20 units (each unit lasts 15 min) distributed over 5 weeks (4 units/week). Data collection was administered both before (pre-test) and after (post-test) the intervention as well as 3 months later (follow-up). Measures included group-administered tests and tasks (spelling, visuo-motor integration, copy task, and composing) and individually administered tests and tasks (working memory and several handwriting tasks on the digitizing tablet). As handwriting automaticity (measured on the digitizing tablet) was already high at the beginning of the study, the intervention was not able to improve it further. In consequence, an intervention effect on the quality of composed texts was not observed. Instead, text quality was predicted by working memory, fluency, spelling, and gender irrespective of the intervention.

The Relationship of Motor Coordination, Visual Perception, and Executive Function to the Development of 4-6-Year-Old Chinese Preschoolers' Visual Motor Integration Skills

Visual motor integration (VMI) is a vital ability in childhood development, which is associated with the performance of many functional skills. By using the Beery Developmental Test Package and Executive Function Tasks, the present study explored the VMI development and its factors (visual perception, motor coordination, and executive function) among 151 Chinese preschoolers from 4 to 6 years. Results indicated that the VMI skills of children increased quickly at 4 years and peaked at 5 years and decreased at around 5 to 6 years. Motor coordination and cognitive flexibility were related to the VMI development of children from 4 to 6 years. Visual perception was associated with the VMI development at early 4 years and inhibitory control was also associated with it among 4-year-old and the beginning of 5-year-old children. Working memory had no impact on the VMI. In conclusion, the development of VMI skills among children in preschool was not stable but changed dynamically in this study. Meanwhile the factors of the VMI worked in different age range for preschoolers. These findings may give some guidance to researchers or health professionals on improving children's VMI skills in their early childhood.

Occupational Therapy for Children with Handwriting Difficulties: A Framework for Evaluation and Treatment

Handwriting is one of the most complex skills that is learnt and taught. It requires motor, sensory, perceptual, praxis and cognitive functions, and the integration of these functions. When the complex nature of this skill is considered, it comes as little surprise that many children experience difficulty in mastering this area.

When an occupational therapist observes that a child referred to the service is having difficulty with handwriting, it becomes necessary for the therapist to administer procedures to identify the strengths and weaknesses that will then become the basis for a remedial programme.

This article presents a conceptual framework for evaluating and treating handwriting difficulties presented by children in mainstream education with specific developmental disorder, such as dyspraxia or dyslexia. The performance components and functional performance of handwriting are briefly reviewed. Both evaluation and intervention procedures are discussed in order to guide the therapist in developing remedial and instructional programmes. The article highlights the unique role of the occupational therapist in evaluating and treating a child's functional performance of handwriting skills.

Construct Validity of Beery's Developmental Test of Visual-Motor Integration for Taiwanese Children

The purpose of this study was to examine the construct validity of Beery's Developmental Test of Visual-Motor Integration (VMI test) and its hierarchical structure of item difficulties for Taiwanese children. The VMI test was administered to 314 Taiwanese children aged from 3.3 to 13.3 years. The Rasch model of measurement was chosen to investigate the goodness-of-fit of individual items within the VMI test and the sequence of item difficulty. The results revealed that the 24 items of the VMI test measure a unidimensional construct. The difficulty levels of the items were spread widely and evenly across the age range tested. A person separation reliability of .92 and an item separation reliability of .99 indicated that the VMI test had good discriminatory power. However, the different sequence of item difficulty preliminarily found in this study indicates that the item order or the scoring criteria should be revised for Taiwanese children. Further studies of the standardization and validity of the VMI test and revision of the sequence for the Taiwanese population are necessary.

The Contribution of Gender, Orthographic, Finger Function, and Visual-Motor Processes to the Prediction of Handwriting Status

The present study examined if orthographic, finger function, and visual-motor processes as well as gender made a unique and significant contribution to the prediction of the handwriting status of fifth grade students classified as good or poor handwriters. Visual-motor integration and finger functioning made a unique and significant contribution to the prediction of handwriting status, whereas gender and orthographic processes did not. Furthermore, knowledge of children's gender, finger functioning, and visual-motor status resulted in the correct classification of 77% of the participating students as good or poor handwriters.

Performance of the Visual-Motor Integration of Preschool Children in Hong Kong

Objective/Background

The Beery–-Buktenica Developmental Test of Visual-Motor Integration (VMI) is an important assessment tool used by occupational therapists working with children. The aims of this study were (a) to identify performance differences in the VMI between Hong Kong preschool children and their counterparts in the United States; (b) to develop local references for the VMI (fifth edition) for the preschool children in Hong Kong; and (c) to examine the dimensionality and the hierarchical ordering of the VMI items using the Rasch Measurement Model (RMM).

Methods

A total of 288 healthy children aged between 3 years and 6 months and 5 years and 11 months were recruited from 54 local preschools in Hong Kong using the multistage sampling method. VMI was administered to the children individually at their preschools.

Results

Hong Kong preschool children were significantly better than those in the United States in VMI performance (p < .001). The results of the RMM showed that the VMI fell within the acceptable levels of unidimensionality. Most items were found to be hierarchically ordered, although a few items were found to have the same level of difficulty.

Conclusion

The local reference developed in this study yielded additional insights for occupational therapists and psychologists with regard to the application of the VMI (fifth edition) for Hong Kong children aged between 3 years and 6 months and 5 years and 11 months.

Examining the relationship between motor assessments and handwriting consistency in children with and without probable developmental coordination disorder

Children with Developmental Coordination Disorder (DCD) often experience difficulties in handwriting. The current study examined the relationships between three motor assessments and the spatial and temporal consistency of handwriting. Twelve children with probable DCD and 29 children from 7 to 12 years who were typically developing wrote the lowercase letters "e" and "l" in cursive and printed forms repetitively on a digitizing tablet. Three behavioral assessments, including the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI), the Minnesota Handwriting Assessment (MHA) and the Movement Assessment Battery for Children (MABC), were administered. Children with probable DCD had low scores on the VMI, MABC and MHA and showed high temporal, not spatial, variability in the letter-writing task. Their MABC scores related to temporal consistency in all handwriting conditions, and the Legibility scores in their MHA correlated with temporal consistency in cursive "e" and printed "l". It appears that children with probable DCD have prominent difficulties on the temporal aspect of handwriting. While the MHA is a good product-oriented assessment for measuring handwriting deficits, the MABC shows promise as a good assessment for capturing the temporal process of handwriting in children with DCD.

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.

Visual-perceptual-kinesthetic inputs on influencing writing performances in children with handwriting difficulties

This study investigated the role of visual-perceptual input in writing Chinese characters among senior school-aged children who had handwriting difficulties (CHD). The participants were 27 CHD (9-11 years old) and 61 normally developed control. There were three writing conditions: copying, and dictations with or without visual feedback. The motor-free subtests of the Developmental Test of Visual Perception (DTVP-2) were conducted. The CHD group showed significantly slower mean speeds of character production and less legibility of produced characters than the control group in all writing conditions (ps<0.001). There were significant deteriorations in legibility from copying to dictation without visual feedback. Nevertheless, the Group by Condition interaction effect was not statistically significant. Only position in space of DTVP-2 was significantly correlated with the legibility among CHD (r=-0.62, p=0.001). Poor legibility seems to be related to the less-intact spatial representation of the characters in working memory, which can be rectified by viewing the characters during writing. Visual feedback regarding one's own actions in writing can also improve legibility of characters among these children.

Handwriting Fluency in Children

This cross-sectional study aimed to (1) construct a model of handwriting fluency in children and (2) explore the impact of fluent handwriting and visual-motor integration on orthographic skills. In a Swiss sample of 93 fourth graders (mean age = 10 years, 7 months; SD = 6.58 months), handwriting speed and legibility were assessed by means of a copying task. Furthermore, automaticity of handwriting, stroke pressure, and stroke frequency were measured on a digitizing tablet, while visual-motor integration and orthographic skills were assessed by means of standardized tests. SEM modeling revealed that automaticity of handwriting, which is associated with both stroke frequency and stroke pressure, predicts handwriting speed as well as orthographic skills. The latter association remained significant even when visual-motor integration, which also proved to be a predictor of orthographic skills, was included in the model. The results are discussed with respect to theories that assume that the automaticity of handwriting is associated with saving cognitive resources.

Writing to dictation and handwriting performance among Chinese children with dyslexia: relationships with orthographic knowledge and perceptual-motor skills

The purpose of this study was to investigate the relationships between writing to dictation, handwriting, orthographic, and perceptual-motor skills among Chinese children with dyslexia. A cross-sectional design was used. A total of 45 third graders with dyslexia were assessed. Results of stepwise multiple regression models showed that Chinese character naming was the only predictor associated with word dictation (β=.32); handwriting speed was related to deficits in rapid automatic naming (β=-.36) and saccadic efficiency (β=-.29), and visual-motor integration predicted both of the number of characters exceeded grid (β=-.41) and variability of character size (β=-.38). The findings provided support to a multi-stage working memory model of writing for explaining the possible underlying mechanism of writing to dictation and handwriting difficulties.

Validation of the Chinese Handwriting Analysis System (CHAS) for primary school students in Hong Kong

There are more children diagnosed with specific learning difficulties in recent years as people are more aware of these conditions. Diagnostic tool has been validated to screen out this condition from the population (SpLD test for Hong Kong children). However, for specific assessment on handwriting problem, there seems a lack of standardized and objective evaluation tool to look into the problems. The objective of this study was to validate the Chinese Handwriting Analysis System (CHAS), which is designed to measure both the process and production of handwriting. The construct validity, convergent validity, internal consistency and test-retest reliability of CHAS was analyzed using the data from 734 grade 1-6 students from 6 primary schools in Hong Kong. Principal Component Analysis revealed that measurements of CHAS loaded into 4 components which accounted for 77.73% of the variance. The correlation between the handwriting accuracy obtained from HAS and eyeballing was r=.73. Cronbach's alpha of all measurement items was .65. Except SD of writing time per character, all the measurement items regarding handwriting speed, handwriting accuracy and pen pressure showed good to excellent test-retest reliability (r=.72-.96), while measurement on the numbers of characters which exceeded grid showed moderate reliability (r=.48). Although there are still ergonomic, biomechanical or unspecified aspects which may not be determined by the system, the CHAS can definitely assist therapists in identifying primary school students with handwriting problems and implement interventions accordingly.

Handwriting movement analyses comparing first and second graders with normal or dysgraphic characteristics

Dysgraphia of sufficient severity to interfere with the school work has been recognized as representing a distinct deficit; characterization of its movement problem is a necessary step toward offering improved intervention. From among children aged 6-8, 69 children with dysgraphic characteristics (study group) and 69 matched proficient hand-writers (control group) were recruited into this study. Four copying tests of differing complexity levels were administered using a digital tablet. The acquired data included direct measure (axial pen tip force) and derived parameters (stroke velocity, pause time, number of velocity peaks and ratio of In Air to On Paper measures). The major finding is that children with dysgraphic characteristics had increased pause time per stroke and an increased number of directional changes in velocity. Significant differences were also found between students in two different grades, especially in the control group. The parameters extracted and observed in this study can further differentiate and characterize the handwriting problems originating from fine motor deficits.

Psychological adjustment and levels of self esteem in children with visual-motor integration difficulties influences the results of a randomized intervention trial

This study evaluates how much the effects of intervention programs are influenced by pre-existing psychological adjustment and self-esteem levels in kindergarten and first grade children with poor visual-motor integration skills, from low socioeconomic backgrounds. One hundred and sixteen mainstream kindergarten and first-grade children, from low socioeconomic backgrounds, scoring below the 25th percentile on a measure of visual-motor integration (VMI) were recruited and randomly divided into two parallel intervention groups. One intervention group received directive visual-motor intervention (DVMI), while the second intervention group received a non-directive supportive intervention (NDSI). Tests were administered to evaluate visual-motor integration skills outcome. Children with higher baseline measures of psychological adjustment and self-esteem responded better in NDSI while children with lower baseline performance on psychological adjustment and self-esteem responded better in DVMI. This study suggests that children from low socioeconomic backgrounds with low VMI performance scores will benefit more from intervention programs if clinicians choose the type of intervention according to baseline psychological adjustment and self-esteem measures.

Age effects on sensory-processing abilities and their impact on handwriting

Background.

Sensory-processing abilities are known to deteriorate in the elderly. As a result, daily activities such as handwriting may be impaired. Yet, knowledge about sensory-processing involvement in handwriting characteristics among older persons is limited.

Purpose

To examine how age influences sensory-processing abilities and the impact on handwriting as a daily performance.

Method.

The study participants were 118 healthy, independently functioning adults divided into four age groups: 31–45, 46–60, 61–75 and 76+ years. All participants completed the Adolescent/Adult Sensory Profile (AASP). Handwriting process was documented using the Computerized Handwriting Penmanship Evaluation Tool (ComPET).

Findings.

Age significantly affects sensory processing and handwriting pressure as well as temporal and spatial measures. Both handwriting time and spatial organization of the written product were predicted by sensory seeking. When examining age contribution to the prediction of handwriting by sensory processing, sensory seeking showed a tendency for predicting handwriting pressure (p = .06), while sensory sensitivity significantly predicted handwriting velocity.

Implications.

Age appears to influence sensory-processing abilities and affect daily performance tasks, such as handwriting, for which sensitivity and seeking for sensations are essential. Awareness of clinicians to sensory-processing deficits among older adults and examining their impact on broader daily activities are essential to improve daily performance and quality of life.

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.

Chinese handwriting performance of primary school children with dyslexia

The aim of this study was to investigate the Chinese handwriting performance of typical children and children with dyslexia, and to examine whether speed and accuracy of handwriting could reliably discriminate these two groups of children. One hundred and thirty-seven children with dyslexia and 756 typical children were recruited from main stream primary schools for the study. They were requested to copy 90 Chinese characters using the Chinese Handwriting Assessment Tool (CHAT) jointly developed by a project team from two universities in Hong Kong. The process of handwriting was recorded and the stroke errors in writing were analyzed using the CHAT system. Results indicated that children with dyslexia wrote significantly slower, with greater average character size and variation in size (p<.05) than the typical children of same age group. They also wrote with significantly lower accuracy (p<.05). Commonly observed writing errors among the Dyslexic group were missing strokes and concatenated strokes. From the discriminant analysis, it was found that writing speed and accuracy were satisfactory discriminators that could discriminate students into the two groups, with reasonably good classification accuracy of over 70% for every grade. The results were discussed with theoretical implications in relation to fine motor skills, kinesthetic abilities, visual perceptual skills, and the demand of written tasks in school.

Standardized tests of handwriting readiness: a systematic review of the literature

AIM

To establish if there are psychometrically sound standardized tests or test items to assess handwriting readiness in 5- and 6-year-old children on the levels of occupations activities/tasks and performance.

METHOD

Electronic databases were searched to identify measurement instruments. Tests were included in a systematic review if: (1) participants are 5 and 6 years old, (2) the focus was on handwriting readiness, and (3) the measurement was standardized. In the second step a further electronic search was undertaken for selected relevant measurement instruments to evaluate the content, psychometric properties, and feasibility of these instruments.

RESULTS

The search identified 1113 citations. In the final selection 39 articles with information about 12 tests were included. The content, feasibility, and psychometric properties of these 12 tests were evaluated and none of the instruments was satisfactory, according to the specific criteria.

INTERPRETATION

None of the instruments include all necessary components to evaluate writing readiness. Therefore, the development of an all encompassing assessment is necessary to test handwriting readiness and to make tailored interventions possible.

Relationships between fine-motor, visual-motor, and visual perception scores and handwriting legibility and speed

Occupational therapists assess fine motor, visual motor, visual perception, and visual skill development, but knowledge of the relationships between scores on sensorimotor performance measures and handwriting legibility and speed is limited. Ninety-nine students in grades three to six with learning and/or behavior problems completed the Upper-Limb Speed and Dexterity Subtest of the Bruininks-Oseretsky Test of Motor Proficiency, the Beery-Buktenica Developmental Test of Visual-Motor Integration-5th Edition, the Test of Visual Perceptual Skills-Revised, the Visual Skills Appraisal, and a handwriting copying task. Correlations between sensorimotor performance scores and handwriting legibility varied from .07 to .38. Correlations between sensorimotor performance scores and handwriting speed varied from .04 to .42. Stepwise multiple regression analysis indicated that the variance in handwriting explained by these measures was ≤ 20% for legibility and ≤ 26% for speed. On the basis of multivariate analysis of variance only scores for the Developmental Test of Visual-Motor Integration differed between students classified as "skilled" and "unskilled" handwriters. The low magnitude of the correlations and variance explained by the sensorimotor performance measures supports the need for occupational therapists to consider additional factors that may impact handwriting of students with learning and/or behavior problems.

The effect of a computerized visual perception and visual-motor integration training program on improving Chinese handwriting of children with handwriting difficulties

This study aimed to investigate the effect of a computerized visual perception and visual-motor integration training program to enhance Chinese handwriting performance among children with learning difficulties, particularly those with handwriting problems. Participants were 26 primary-one children who were assessed by educational psychologists and occupational therapists to have handwriting difficulties. They were matched according to their age and then randomly assigned into either the control group or the experimental group. Subjects in the experimental group (n=13) would receive eight sessions of computerized visual perception and visual-motor integration training together with a home training program while those in the control group (n=13) would only receive conventional handwriting training by teachers, which focused mainly on remedial handwriting exercises. Results from repeated measure ANOVA revealed that children in the experimental group showed improvements in their visual perception skills as well as in their handwriting time. Both the "On Paper" time and "In Air" time of this group were improved when compared to the control group. However, no significant differences were found in visual-motor integration skill and handwriting legibility between the two groups after the intervention. This computerized training program focusing on visual perception and visual-motor integration training appeared to be effective in enhancing the handwriting time among children with handwriting difficulties. However, the training program did not seem to improve the legibility of children.

Relationship Between Handwriting and Keyboarding Performance Among Fast and Slow Adult Keyboarders

OBJECTIVE. We examined the relationship between handwriting and keyboarding performance and between these writing modes and underlying performance skills.

METHOD. Sixty-three young, healthy adults who used the computer daily were recruited for this study by means of a convenience sample (mean = 25.3, standard deviation = 3.0); 15 were slow keyboarders and 17 were fast keyboarders. Participants were administered handwriting and keyboarding assessments, as well as measures of finger function, kinesthetic processing, and eye movement.

RESULTS. Although handwriting and keyboarding speed were moderately correlated, these activities did not share underlying performance skills. In addition, different correlation patterns between written communication modes and performance skills were found among slow and fast keyboarders.

CONCLUSION. Results suggest that occupational therapists and educators should consider a variety of factors before recommending keyboarding as an alternative written communication method for people with handwriting difficulties. Moreover, different recommendations appear to be warranted for slow and fast keyboarders.

Discriminant Validity of the Visual Motor Integration Test in Screening Children with Handwriting Dysfunction

To examine the discriminant validity of the Visual Motor Integration test in screening children with handwriting dysfunction, 599 children in Grade 2, including 41 children with handwriting dysfunction identified by their teachers and 558 typically developing children, were assessed. The Visual Motor Integration test, with an area under the receiver operating characteristic curve (0.894), showed high accuracy regarding screening purposes. Judging from the values for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, hit rate, Youden's index, and odds ratio, a standard score of 85 was the best cutoff point for screening children for handwriting dysfunction.

Comparing different short-term service delivery methods of visual-motor treatment for first grade students in mainstream schools

To compare the efficacy of three different short-term service delivery methods on first grade children with soft neurological signs who suffer from visual-motor difficulties. One hundred and forty seven first grade students who scored below the 21st percentile on the Visual-Motor Integration Test (VMI) were recruited from schools and randomly divided into three intervention groups and an additional control group. One group received Direct Treatment Model (DT), the second group received Collaborative-Consultation Treatment Model (CC) and the third group received a Combined Treatment Model (CT). The CC included treatment administered by teachers, after Collaborative-Consultation with an occupational therapist (OT). The CT included the two models (DT, CC), administered simultaneously. Pre- and post-intervention tests were administered to both groups. Students in all three intervention groups made significant gains in comparison to the control group suggesting that all three service delivery methods had the same effect on children's visual-motor skills. Therapists in school settings who are obliged to be more efficient are encouraged to use the CC or the CT service delivery methods which would enable them to treat more children during the same time-frame, with full confidence that the treatment goals will be achieved as if using the DT.

The Preliminary Development of Computer-Assisted Assessment of Chinese Handwriting Performance

This paper describes a pilot study investigating an assessment for Chinese handwriting performance. In an attempt to computerize the existing Tseng Handwriting Problem Checklist (Tseng Checklist), this study employed MATLAB to develop a computer program entitled the Chinese Handwriting Assessment Program (CHAP) to be used for the evaluation of handwriting performance. Through a template-matching approach, the program processed each character by using size-adjustable standard models to calculate the two-dimensional cross-correlation coefficient of a template and a superimposed handwritten character. The program measured the size control, spacing, alignment, and the average resemblance between standard models and handwritten characters. The results of the CHAP's test-retest reliability showed that the high correlation coefficients (from .81 to .94) were statistically significant. Correlations between each CHAP and Tseng Checklist item were statistically significant. As these assessment tools for handwriting performance are required for quantitative and qualitative aspects, the integration of the two tools is a promising means for accomplishing a handwriting performance assessment.

Cognitive versus Multisensory Approaches to Handwriting Intervention: A Randomized Controlled Trial

The purpose of this study was to compare the effect of cognitive versus multisensory interventions on handwriting legibility of elementary school students referred to occupational therapy for handwriting difficulties. In this randomized controlled trial, 72 first- and second-grade students were assigned to either a cognitive intervention, multisensory intervention, or control (no intervention) group. Letter legibility was measured using the Evaluation Tool for Children's Handwriting before and after 10 weeks of intervention. Analysis of variance of change scores showed no statistically significant difference across the three groups. First-grade students improved with or without intervention, but second-grade students showed sizeable improvement with cognitive intervention compared to multisensory intervention ( d = 1.09) or no intervention ( d = .92). These results challenge current occupational therapy practice of using a multisensory approach for remediation of handwriting difficulties for students in second grade. A cognitive approach to handwriting intervention shows greater promise and is worthy of further investigation.

Handwriting performance in children with attention deficit hyperactivity disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral condition of childhood. Consequences are multifaceted and include activity limitations in daily-living skills, academic challenges, diminished socialization skills, and motor difficulties. Poor handwriting performance is an example of an affected life skill that has been anecdotally observed by educators and clinicians for this population and can negatively impact academic performance and self-esteem. To guide health and educational service delivery needs, the authors reviewed the evidence in the literature on handwriting difficulties in children with ADHD. Existing evidence would suggest that children with ADHD have impaired handwriting performance, characterized by illegible written material and/or inappropriate speed of execution compared to children without ADHD. Studies with larger sample sizes using standardized measures of handwriting performance are needed to evaluate the prevalence of the problem and to better understand the nature of handwriting difficulties and their impact in this population.

Learning, attention, writing, and processing speed in typical children and children with ADHD, autism, anxiety, depression, and oppositional-defiant disorder

Learning, attention, graphomotor, and processing speed scores were analyzed in 149 typical control children and 886 clinical children with normal intelligence. Nonsignificant differences were found between control children and children with anxiety, depression, and oppositional-defiant disorder. Control children performed better than children with ADHD and autism in all areas. Children with ADHD and autism did not differ, except that children with ADHD had greater learning problems. Attention, graphomotor, and speed weaknesses were likely to coexist, the majority of children with autism and ADHD had weaknesses in all three areas, and these scores contributed significantly to the prediction of academic achievement.