A Short-Term Graphomotor Program For Improving Writing Readiness Skills of First-Grade Students
A Short-Term Graphomotor Program For Improving Writing Readiness Skills of First-Grade Students
A Short-Term Graphomotor Program For Improving Writing Readiness Skills of First-Grade Students
KEY WORDS OBJECTIVE. Children with fine-motor problems and handwriting difficulties often are referred for occupa-
• Arab tional therapy. The objective of this study was to test the efficacy of a short-term treatment on the fine-motor
• graphomotor skills and graphomotor skills of first-grade students.
• handwriting METHOD. We recruited 52 first-grade students who had scored below the 21st percentile on the
Visual–Motor Integration test from schools in a city with a low socioeconomic, mixed (Arab and Jewish) pop-
• Jewish
ulation. The children were randomly divided into an intervention group and a control group. Before and after
• pediatrics
the intervention, we administered two tests to both groups.
• school-based occupational therapy
RESULTS. Students in the intervention group made significant gains both in the total score on the grapho-
motor test (Developmental Test of Visual Perception) and on the fine-motor test (Bruininks–Oseretsky Motor
Development Scale).
CONCLUSION. This study provided preliminary evidence of the efficacy of a short-term graphomotor inter-
vention. The results increased the feasibility of implementing occupational therapy intervention in the Israeli
school system, allowing treatment of more children using the same resources.
Ratzon, N. Z., Efraim, D., & Bart, O. (2007). A short-term graphomotor program for improving writing readiness skills of first-
grade students. American Journal of Occupational Therapy, 61, 399–405.
Navah Z. Ratzon, PhD, is Senior Lecturer, Sackler Fac- bservation of daily activities in regular elementary school classrooms has
ulty of Medicine, School of Health Professions, Depart-
ment of Occupational Therapy, Tel Aviv University, P.O.B.
O revealed that between 30% and 60% of the school day is devoted to fine-motor
activities, such as cutting and coloring, and especially to writing tasks, which pre-
39040, Tel Aviv 69978 Israel; navah@post.tau.ac.il.
dominate over other manipulative tasks (Linder, 1986; McHale & Cermak, 1992).
Daniela Efraim, MSc, OT, was Graduate Student in the Most children ages 6 to 7 years are mature enough to be able to carry out these
Department of Occupational Therapy, School of Allied
Health Medical Facility, Tel Aviv University, at the time of
assignments (McHale & Cermak, 1992; Weil & Cunningham Amundson, 1994).
this study. Nevertheless, 10% to 20% of students experience visual–motor delay to various
degrees (Hamstra-Bletz & Blote, 1993; McHale & Cermak, 1992; Schneck,
Orit Bart, PhD, OTR, is Lecturer in the Department of
1991). Visual–motor problems may interfere with the child’s ability to acquire
Occupational Therapy, School of Allied Health Medical
Faculty, Tel Aviv University. writing skills and to fully participate in student activities.
Because of the negative effects of handwriting difficulties on a child’s academic
performance and self-esteem (Margalit, 1998; Pavri & Monda-Amaya, 2000),
early evaluation and treatment of visual–motor problems among first-grade stu-
dents are of major importance. Moreover, the disparity between children with
visual–motor difficulties who are not treated and their classmates tends to remain
constant as the children age (Marr & Cermak, 2001). Reducing the disparity in
first grade is crucial; research has shown that healthy adjustment during the first
years of school is a precursor of subsequent school success and that individual dif-
ferences in children’s school results remain relatively stable after the first few years
in school (e.g., Alexander, Entwisle, & Olson, 2001).
First-grade students’ handwriting cannot as yet be assessed in Israel. Hand-
writing skills in Hebrew cannot be evaluated until the second school year, when
The American Journal of Occupational Therapy 399
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children have acquired efficient writing skills (Lifshitz & criteria: (a) an occupational therapist was on staff at the
Parush, 1999). The lack of valid assessment procedures for school, (b) the school provided an occupational therapy
first graders limits the ability of Israeli professionals to accu- room, and (c) the school made an unambiguous commit-
rately assess children’s prewriting skills, which are necessary ment to allow us to carry out the study. Students attending
for participation in first grade. This constraint dictates hav- these schools came from a low socioeconomic, mixed Arab
ing to assess the child’s performance capacity related to and Jewish population.
handwriting. Many researchers consider assessing the child’s All first-grade students attending the schools (198 chil-
graphomotor skills to be an acceptable parameter for evalu- dren) were administered the Beery–Buktenica Developmen-
ating writing readiness (Beery, 1997; Daly, Kelley, & Krauss, tal Test of Visual–Motor Integration (VMI; Beery, 1997).
2003; Laszlo & Broderick, 1991). Visual–motor skill is an Low scores indicate poor visual–motor skills, and study par-
important component of success in writing. Individual dif- ticipants who scored lowest on the VMI test were selected.
ferences in visual–motor integration are significantly related Scores of 25% to 75% are considered average (Beery, 1997);
to academic performance and social competence in young a score of 21% or lower was the cutoff point for this study.
children (Schoemaker & Kalverboer, 1994; Taylor, 1999). Seventy-one children (36%) scored under the cutoff point.
Specific links also have been found between Seven exclusion criteria were applied to participants:
visual–motor integration and writing quality (e.g., Levine, 1. A medical diagnosis indicating a central nervous system
1987; Tseng & Chow, 2000) and between kinesthesia and dysfunction such as mental retardation, cerebral palsy,
handwriting development (Lazlo & Bairstow, 1984). or autism (0 children excluded);
Therefore, early identification of handwriting or grapho- 2. Severe sensory loss (i.e., visual or auditory impairment;
motor integration problems and subsequent adequate inter- 0 children excluded),
vention may decrease the child’s difficulties. Indeed, occu- 3. Indication of emotional, behavioral, or mental prob-
pational therapy intervention has been found to improve lems as reported by the teachers (10 children excluded),
visual–motor skills in preschool children and children in 4. Participation in the special education program with part-
their first years of school (Dankert, Davis, & Gavin, 2003; time inclusion in regular classes (2 children excluded),
Oliver, 1990; Parush & Hahn-Markowitz, 1997). Never- 5. Participation in intervention by an occupational ther-
theless, even when there is evidence of a treatment’s effec- apy or physiotherapy professional (0 children excluded),
tiveness, economic and organizational factors place external 6. Withholding of consent by parents (0 children
parameters on occupational therapists’ abilities to incorpo- excluded), and
rate evidence into their practices (Rappolt, 2003). For these 7. Failure to complete the study program because of
reasons, occupational therapists in school settings primarily repeated absence from school (7 children excluded).
treat children with severe impairments, whereas children Fifty-nine children meeting the criteria were randomly
with mild impairments do not receive the help they need divided into the treatment and the control groups. During
(Reisman, 1991). the study, 3 children from the control group and 4 from the
In the present study, we attempted to incorporate prac- treatment group dropped out because of Criterion 7. There
tice demands into the study design, which adapted the cur- were 24 participants in the treatment group (13 boys, 11
rent approach among health professionals to shorten treat- girls) and 28 participants in the control group (12 boys, 16
ment (Valmaggia, Van der Gaag, Tarrier, Pijnenborg, & girls). The ratios of boys to girls were similar in both groups
Slooff, 2005) to make interventions effective and economic. (χ2[1, N = 52] = 0.66, p = ns).
The objective of the study was to assess the efficacy of a
short-term intervention on visual–motor skills in first-grade Measures
students from low socioeconomic backgrounds. Specifically, Visual–Motor Integration Test. The Beery–Buktenica
we hypothesized that the visual–motor scores of the chil- Developmental Test of Visual–Motor Integration (Beery,
dren in the treatment group would be higher after the inter- 1997) is a developmental sequence of geometric forms to be
vention than the scores of children in the control group. copied with paper and pencil. The school occupational
therapist administered all 27 items by group procedure in
the classroom in about 10 to 15 min. The test is reliable and
Method valid (Beery, 1997) and commonly is used for screening
purposes. In our participants’ schools, the school occupa-
Participants
tional therapist uses this test (with parental consent) at the
The study participants were first graders from four elemen- beginning of each year to screen first graders. It was thus
tary schools in Jaffa, Israel. The schools met the following administered as a regular classroom procedure.
400 July/August 2007, Volume 61, Number 4
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Developmental Test of Visual Perception. The Develop- coins, screws, screw nuts, and other items. The pencil-and-
mental Test of Visual Perception (DTVP–2; Hammill, paper layouts included pattern molds for drawing and vari-
Pearson, & Voress, 1993) includes eight subtests; we ous worksheets with activities such as connecting numbers,
administered only four that measure visual–motor perfor- dots, or arrows; coloring by numbers; and tracing mazes.
mance: eye–hand coordination, copying, spatial relation- As part of their fieldwork, 10 occupational therapy stu-
ships, and visual–motor speed, all motor-related measures. dents administered the intervention sessions to two stu-
The norms for the DTVP–2 were developed using a sam- dents at a time in the school’s occupational therapy room.
ple of 1,972 children 4 to 10 years old. Test–retest reliabil- All activity tools were prepared in advance in 12 kits, one
ity for the DTVP–2 (n = 88) ranged from r = .71 to r = .86 for each week’s session. An experienced pediatric occupa-
and was r = .96 for the total score. Interrater reliability (n = tional therapist supervised all occupational therapy students
88) was r = .98 for the total test (Hammill et al., 1993). each week, guiding them in using the kit and analyzing the
One of the authors administered the test before and after children’s performance on the previous session.
the intervention, and scoring was completed by an occupa-
tional therapist who was not familiar with the study groups
or the hypothesis. Procedure
Bruininks–Oseretsky Motor Development Scale. The The office of the Israeli education ministry approved this
Motor Development Scale of the Bruininks–Oseretsky Test study. All parents of the first-grade students signed consent
of Motor Proficiency (Bruininks, 1978) was designed to forms for the VMI; the forms specified that if necessary, the
assess children’s motor development and to measure their study would include further evaluation (i.e., the DTVP–2
gross- and fine-motor skills. This study used only a sum- and Bruininks–Oseretsky test) and intervention.
mary score of Subtest 8 from the fine-motor scale, which Children who scored below the VMI cutoff point com-
includes evaluations of visual–motor control and finger pleted the DTVP–2 and the Bruininks–Oseretsky test
coordination. An occupational therapist administered the before and after intervention. After the first evaluation, they
test. Because of technical problems, only 15 of 24 children participated in 12 intervention sessions.
in the study group and 24 of 28 children in the control
group were administered the Bruininks–Oseretsky test.
Statistical Analysis
We used raw scores rather than standard scores or per-
Graphomotor Intervention centiles to compare mean scores (Wilson, Polatajko,
The short-term intervention program we used, developed Kaplan, & Faris, 1994) because of the 12-week difference
by Efraim (2002) as part of the requirements for her mas- between the pretest and posttest scores (the children’s ages
ter’s degree, encourages writing skills in first-grade children. were matched between the two groups) and because, for
The intervention is based on three lines of reasoning: Israel, it is more appropriate to use raw data than to trans-
1. Motor learning theories, which hold that for a client to form the scores to U.S. norms. To ensure that this strategy
improve, the practiced tasks should be as similar as pos- was correct, we standardized the scores by calculating the
sible to the required assignment (Polatajko et al., 1995); difference between the results as percentages relative to
2. Multisensory theory (Lockhart & Law, 1994); and each individual pretest score according to the following
3. Research that found associations between dexterity formula:
skills and normal development of visual–motor profi-
Posttest score – Pretest score
ciency (Benbow, 1995; Cornhill & Case-Smith, 1996; × 100
Pretest score
Humphry, Jewell, & Rosenberg, 1995; Levine, Oberk-
laid, & Melzer, 1981). The differences between the study and the control groups
The activities and tools chosen for this intervention pro- were very small. Therefore, we used the raw scores.
gram also were based on our clinical experience and Ben- We used one-way multiple analysis of variance
bow’s (1995) recommendations. (MANOVA) to determine group differences between study
The intervention included 12 sessions, each held once and control participants on four DTVP–2 pretest scales and
a week for 45 min. The first 10 to 15 min of each session the VMI. No significant differences were found between
were dedicated to playful fine-motor activities and the the groups on each of the measures (multivariate Wilks’s
remaining 30 to 35 min exclusively to pencil-and-paper F [6, 45] = 0.97, p = ns).
activities. Fine-motor activity layouts included threading Because of missing data from the Bruininks–Oseretsky
beads; inserting pegs; and undertaking guided play with test, we analyzed the dependent variables (DTVP–2 and the
The American Journal of Occupational Therapy 401
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Bruininks–Oseretsky test) separately. To determine the effect same pattern of improvement. Treatment group partic-
of the intervention on the treatment group, we conducted ipants improved their mean score of 23.1 to a posttest
repeated MANOVA measures (Time × Group × DTVP–2 mean of 35.8, whereas control children improved their
measures) on four raw score measures from the DTVP–2 mean scores from 24.3 to 29.1.
tests, and we conducted repeated ANOVA measures to com- Repeated ANOVA measures comparing treatment and
pare the total DTVP–2 standard scores and Bruininks– control groups’ Bruininks–Oseretsky test scores revealed a
Oseretsky raw test scores of the study and control groups. significant interaction effect (F[1, 37] = 31.47, p = .000).
Because the study population consisted of both Arab Treatment participants improved their mean score from
and Jewish children, we performed further analyses of 19.0 to 27.2, whereas control participants remained rela-
demographic differences. We performed two- and three- tively steady at 20.0 pretest and 21.4 posttest.
way ANOVAs to measure the effect size of population Univariate ANOVAs for the standardized scores indi-
group. cated significant differences between groups in eye–hand
coordination scores (F[1, 50] = 6.24, p < .05), copying
scores (F[1, 50] = 11.37, p < .001), spatial relationships
Results scores (F[1, 50] = 13.97, p < .001), and total DTVP–2
We compared the groups by age (t[50] = 0.58, p = ns). The standard scores (F[1, 50] = 13.62, p = .001). The treatment
treatment group had a mean age of 80 months (SD = 4 group improved its scores on these measures by at least
months, range 72–88 months), and the control group had 60%, whereas the control group improved its scores by no
a mean age of 79 months (SD = 4 months, range 73–89 more than 47%. The standard DTVP–2 score was higher by
months). Both groups included Jewish and Arab partici- a mean of 7.5 points among the treatment group and by a
pants (treatment group, 14 Arab participants; control mean of 2.7 points among the control group (Table 2).
group, 17 Arab participants; χ2[1, N = 52] = 0.03, p = ns).
Analysis of Demographic Effects
Hypothesis Testing Three-way repeated MANOVA measures revealed a signifi-
Results indicated a significant interaction (Time × Group) cant interaction of Group × Religion × Time in eye–hand
in three of the four measures of the DTVP–2 (Table 1): coordination raw scores (F[1, 48] = 4.01, p = .05). Addi-
1. The eye–hand coordination measure showed signifi- tional two-way (Group × Religion) ANOVAs for different
cant improvement in the treatment group from a mean scores indicated higher improvement among Jewish treat-
score of 135.0 to a mean score of 152.8, whereas con- ment participants (M = 70.3% improvement, SD = 30.8)
trol group mean scores improved from 143.6 to 149.3 than Arab participants (M = 55.1% improvement, SD =
(F[1, 50] = 6.41, p < .02). 17.9). The scores of control participants from both religious
2. Children in the treatment group improved their mean groups did not differ significantly (Jewish participants, M =
copying scores significantly more than the control chil- 35.4, SD = 29.6; Arab participants, M = 45.3, SD = 33.7).
dren, from 16.0 to 19.6 (F[1, 50] = 7.70, p < .01); con- The ANOVA comparison for Group × Religion was not
trol children improved their performance only slightly, statistically significant. Three-way repeated MANOVA
from a mean score of 16.6 to a mean score of 17.7. measures revealed a nonsignificant interaction of Group ×
3. A significant interaction effect (F[1, 50] = 16.22, p < Gender × Time in DTVP–2 scores (multivariate F[4, 45] =
.001) on the measure of spatial relations indicated the 2.28, p = ns).
Table 1. DTVP–2 and Bruininks–Oseretsky Raw Scores of Study and Control Groups Before and After Intervention
Before Intervention After Intervention
Study Group Control Group Study Group Control Group
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