HE DEVELOPMENT OF GRAPHOMOTOR - Edlantis output (Mathiowetz & Bass-Haugen, 2002). ... The...

Chapter 11THE DEVELOPMENT OFGRAPHOMOTOR SKILLS

Jenny Ziviani • Margaret Wallen

CHAPTER OUTLINE

GENERAL GRAPHOMOTOR COMPETENCY

Acquisition of Graphomotor Skills

Implement Grasp and Manipulation

DRAWING

The Nature of Drawing

Computers and Drawing

Drawing and Developmental Evaluation

HANDWRITING

Handwriting and Writing: Complementary Concepts

The Developmental Nature of Handwriting

Factors Contributing to Handwriting Performance

Computers and Handwriting

SUMMARY

This chapter provides information on the developmentand execution of graphomotor skills, as a basis forremediation. Concepts common to both drawing andhandwriting such as motor learning theory and graspsused with writing and drawing tools are discussed first.Following are detailed sections on drawing and thenhandwriting. The emphasis in these sections is onoutlining research that broadens our knowledge of thedevelopment of drawing and handwriting and deepensour understanding of the factors that are associatedwith graphomotor difficulties.

Graphomotor skills comprise those conceptual andperceptual-motor abilities necessary for drawing andhandwriting. Drawing is defined as the art of producinga picture or plan with implements such as pencils, pens,or crayons. Handwriting is the process of forming

letters, figures, or other significant symbols, predomi-nantly on paper. Both these activities can be used torecord experiences or thoughts, as well as communicatethese to others. Drawing and handwriting are com-plex motor behaviors in which psychomotor, linguistic,and biomechanical processes interact with matu-rational, developmental, and learning processes (Smits-Engelsman & Van Galen, 1997). The need to developproficiency in activities as fundamental as drawing andhandwriting may be questioned in relation to thegrowing reliance on electronic communication devices.It is the position of this chapter that graphomotor skillsrepresent more than a means of recording thoughts orconveying experiences. Developmentally these skillsallow for experimentation and self-expression in theway a child interacts with the environment. Further-more they are a means by which children learn basictool use and are able to produce a product that issocially recognized and rewarded. As such they form animportant part of the development of an individual.

GENERAL GRAPHOMOTORCOMPETENCY

ACQUISITION OF GRAPHOMOTOR SKILLS

Children, when presented with tools for inscription,readily smear paint, scribble with crayons, or draw. Thenature of the inscription varies depending on thedevelopmental status of individuals and their motorlearning in relation to prior exposure to graphomotorexperiences. In its most basic form simple inscriptionwith an implement onto a page can be understood as aperceptual-motor act (van Galen, 1991). The learningof a skilled task such as handwriting or drawing,

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however, involves an interplay among the individual,task, and environment (Shumway-Cook & Woollacott,2001). Figure 11-1 summarizes these with respect tohandwriting (Jongmans et al., 2003; Shumway-Cook& Woollacott, 2001). Each child’s individual capacityto mesh the task and the environmental contributionsto handwriting determines the extent to which effectivehandwriting will be acquired.

Motor LearningHandwriting and drawing have been conceptualized aslearned motor tasks. Motor learning theorists explainthe control of coordinated movement in terms of open-and closed-loop systems (Mathiowetz & Bass-Haugen,2002; McGill, 1998). The closed-loop system involvesafferent feedback. In the case of handwriting, feedbackis received from the pressures exerted on the writingimplement and the writing surface, from the senses oftouch and movement in the fingers, hand, and arm,and from visually monitoring written work. This affer-ent feedback is used to update the nervous systemabout the accuracy of the handwriting. The feedback is

used to modify and control subsequent handwriting. Inopen-loop control systems there is no afferent feedbackand the central nervous system directs movement.

Theorists have postulated that the acquisition ofdrawing and handwriting skills can be understood bestwithin the framework of a closed-loop theory. That is,afferent feedback is relied on to learn the skill. How-ever, once learned, it is postulated that handwritingmoves into the domain of an open-loop skill (van derMeulen et al., 1991). This means that instead ofremaining dependent on vision and other sensory feed-back, the skilled writer is able to write so quickly thatthere is no time to modify performance on the basis ofafferent feedback. Movements that are entrenched inmemory may predominate as handwriting becomes aproficient skill (Grossberg & Paine, 2000). In reality,the environmental and task demands of handwritingare diverse and dynamic and preprogrammed motoracts are not adequate to respond to the changingrequirements of various handwriting tasks. Consequent-ly it is more likely that closed- and open-loop systemswork cooperatively, interacting with the various indi-vidual task and environmental factors to achieve hand-writing output (Mathiowetz & Bass-Haugen, 2002).

The Roles of Vision and KinesthesisVision is essential to children learning to handwrite as they plan, execute, and monitor their attempts.Reliance on vision generally diminishes as skilledhandwriting develops and feedback provided by thesomatosensory system has greater influence in directingskilled and precise movement (Cornhill & Case-Smith,1996). However, the visual sense is thought to remainactive in children who are experiencing difficulties inmastering handwriting. Wann (1987) found that goodand poor writers used different movement patterns whenasked to reproduce letters and words. Wann recordedthe performance of good and poor handwriters using anxy digitizer, and movement patterns were categorizedaccording to their velocity and acceleration characteris-tics. Poor handwriters used more patterns of movementindicative of reliance on visual feedback as a majorsource of environmental information during hand-writing. Although not suggesting that the moreproficient writers were not using visual feedback duringletter production, Wann (1987) postulated that theywere probably less dependent on it as a means of con-trol. He went on to point out that deprivation of visualfeedback resulted in the deterioration of even the mostproficient writer’s performance. Other researchers (vander Muelin et al., 1991) have supported the view ofWann and suggest that children with difficulty in visual-motor control compensate by adopting a greater relianceon visual monitoring and that this in turn results inslower performance. These issues warrant greater atten-

218 Part II • Development of Hand Skills

Individual

• Sensory perception• Cognition• Motor control• Affective state• Motor planning• Biomechanical considerations

Task

• Demands of task (cognitive, attentional, linguistic)• Nature of task (copied, self-generated, creative, academic)• Speed and accuracy• Skilled manipulative task

Environment

• Writing materials (implements, paper)• Furniture• Ambient features (temperature, lighting, noise)• Expectations of others• Exposure to instruction and practice

SkilledHandwriting

Figure 11-1 Skilled handwriting demands interplayamong the individual, the task, and the environment.

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tion because they can influence the adoption of appro-priate remedial strategies.

The role of kinesthesia is frequently discussed inrelation to drawing and, particularly, handwriting.Kinesthesis relates to the information received frommuscles, joints, and skin about body and limb position,and the direction, extent, and velocity of movement(Harris & Livesay, 1992; Sudsawad et al., 2002). Animpairment of kinesthesis may influence the refinementof fine motor skills; children are not able to perceiveand therefore monitor and correct errors of movement,particularly those of small amplitude, which areobserved in handwriting (Harris & Livesay, 1992).

Much of the work around kinesthesis in relation tohandwriting involves the Kinesthetic Sensitivity Test(KST). This norm-referenced test consists of two sub-tests: Kinesthetic Acuity and Kinesthetic Perceptionand Memory. Each subtest has specific equipment thatwas designed to eliminate the need for motor control,thus allowing passive movement of children’s handsand arms to determine kinesthetic ability. Laszlo andBairstow (1985a) developed the test to identifykinesthetic deficits and reported that training childrenusing this test equipment resulted in improved drawingskills in children with poor kinesthesis. However, therelative importance of the role of kinesthesis in acqui-sition of proficient handwriting remains unclear. Thissubject is elaborated on in the review of handwritinglater in this chapter.

IMPLEMENT GRASP AND MANIPULATION

Brushes, crayons, pencils, felt-tip markers, and pens arethe primary tools used by children in their graphicendeavors. These implements form an extension of thehand, and their control and manipulation are impor-tant in attaining skilled copying, drawing, and hand-writing. Only through experimentation do childrenbecome skilled in adapting to implements of differentweight, length, and graphic quality. Different graspsmay be adopted with a change in implement and taskto achieve an optimal outcome (Schwartz & Reilly,1980; Thelen & Smith, 1994).

GraspsMany children acquire a dynamic tripod grip by about61⁄2 years of age as their means of implement manipula-tion for drawing and handwriting. Children progressthrough a range of precursor grips—palmar, incom-plete tripod (or palmar supinate), and static tripod—before adopting the dynamic tripod grip (Dennis &Swinth, 2001; Rosenbloom & Horton, 1971; Saida &Miyashita, 1979). Schneck and Henderson (1990)propose a 10-grip scale to classify the developmentalrange of grasps. Level 1, or the lowest level of the scale,

describes a palmar grasp, whereas Level 10 describes a dynamic tripod grasp. The scale is a “whole-configuration system,” which means that all the com-ponents of the grip can be described together ratherthan evaluating various components of a grip separately.Adoption of a scale such as this has the potential toinform comparisons with and between children and to contribute to a system of uniform terminology(Windsor, 2000).

The dynamic tripod grasp, generally viewed as themature grasp, is one in which the writing implement isgrasped between the radial surface of the middle fingerand the pulp surface of the thumb and index finger,with the thumb relatively opposed (Elliott & Connolly,1984). However, not all children acquire or use thisgrip. Research suggests that the dynamic tripod is usedby only 50% to 70% of children in a given sample(Benbow, 1987; Blote & van der Heijden, 1988; Dennis& Swinth, 2001; Schneck & Henderson, 1990). Othergrasps, such as the lateral tripod and quadripod, alsoallow ulnar stability and controlled dynamic fingermovement, which are considered important for skilledhandwriting.

Diverse ways of categorizing variations in thedynamic tripod grip have been used. Ziviani & Elkins(1986) used a series of four nonexclusive categoriesthat described grips on the basis of the number offingers held on the shaft of the writing implement,degree of forearm supination, hyperextension of thedistal interphalangeal joint of the index finger, andthumb and index finger opposition. Sassoon, Nimmo-Smith, and Wing (1986) used a classification of penholds that examined the position of digits on the pencilshaft, their proximity to the writing tip, and the shapeof the digits. Furthermore, Sassoon described grips inrelation to the shaping of the hand, the positioning ofthe upper body, and the specific orientation of thewriting paper. Neither Sassoon nor Ziviani’s studiesfound writing speed was compromised by unconven-tional pencil holds. Subsequent studies have confirmedthat grips affect neither legibility (Koziatek & Powell,2003) nor the undertaking of long writing passages(Dennis & Swinth, 2001). However, all these studieshave been undertaken with children without identifieddisabilities, and have not taken into account the dynamicaspect of adopted grips.

Schneck (1991) found that children who usedvariants of the dynamic tripod grip also had impairmentof proprioceptive/kinesthetic finger awareness. Schneckhypothesized that the grips may not themselves lead to poor handwriting but, in conjunction with poorproprioceptive and kinesthetic perception, mightcontribute to poor handwriting performance. Researchthat examined the impact of joint laxity has supportedthis view (Summers, 2001). In Summers’ study, positive

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but nonsignificant trends emerged between joint laxityand the failure to develop a dynamic tripod grip in 557-year-old children.

Poorly established hand preference has been linkedto developmentally immature grips (Rosenbloom &Horton, 1971; Schneck, 1989), but also can resultfrom insufficient prerequisite experience. Poor handpreference is thought to impede the refinement of themanipulative skills needed for good pencil control. Thisview is consistent with Exner’s (1990) posit that thedevelopment of in-hand manipulation skills is depen-dent on well-defined hand preference.

In a practical and clinical sense, therapists are con-fronted by the issue of whether to assist children tomodify the grip they are using as part of an overallstrategy to facilitate an improvement in handwritingperformance. The following points may be worthconsidering when this situation arises:1. Mechanically the dynamic tripod grip offers a high

level of precision and control (Elliott & Connolly,1984). The dynamic tripod grip should be encour-aged when the child is young enough and has notdeveloped a fixed writing posture. In fact some haveargued that inadequate training in the use of a dynamictripod grip is one of the reasons it is not used bygreater numbers of children (Benbow, 1995).

2. Variations of the dynamic tripod grip do not, ofthemselves, contribute to handwriting difficulties.In typically developing students there appears to beno difference in the speed or legibility of hand-writing using the dynamic tripod versus atypicaldynamic grasps (Dennis & Swinth, 2001; Sassoon,et al., 1986; Ziviani & Elkins, 1986). Differentia-tion should be made, however, between a modifiedversion of the dynamic tripod grip and a grip that isdevelopmentally immature. The latter may be partof a broader picture of developmental difficulty.More research is necessary to determine if there is arelationship between typical and atypical grasps andlegibility in children who are poor handwriters(Schneck, 1991).

Writing ImplementsA further issue related to implement manipulation isthe nature or type of writing tool used. Traditionallyyoung writers are given lead pencils with a larger thannormal lead and barrel for drawing and handwritinginstruction. This practice is based on the premise that itis easier for their small hands to hold and manipulate alarger barrel. However, studies have demonstrated thatthe legibility of kindergarten children’s handwriting isnot associated with the tool used (Oehler et al., 2000).The maturity of grasp employed, nevertheless, mayvary with the specific tool used (Yakimishyn & Magill-Evans, 2002).

This section of the chapter outlined the processesinvolved in acquiring proficient use of tools for drawingand handwriting and about the grasps used whenmanipulating these tools. The next section is about thedevelopment of drawing ability.

DRAWING

THE NATURE OF DRAWING

When considering drawing, the simple copying ofshapes and figures should be differentiated from thecreation of pictures from memory or imagination. Thepresent discussion is concerned primarily with copyingskills (the perceptual-motor elements of drawing).

Certain characteristics are thought to distinguishyounger children’s drawings from those of adults.Children’s drawings have been described as beingformula-like and depicting subjects as they areperceived to be rather than how they look (Freeman,1980). Apart from exceptional children (Selfe, 1985),most children in their preschool and early school yearsconstruct their drawings from simple geometric formsand do not compose broad outlines that are thendetailed. Fenson (1985), in a detailed longitudinalstudy of one child, found that a fundamental shiftoccurred between 3 and 7 years of age in the structureof drawing. The child moved from a constructionalstyle to the use of contoured forms.

The term constructional in this context relates to theassembling of simple geometric forms into a pictorialrepresentation (e.g., the use of a circle for a face and arectangle for a body when drawing a person). The termcontoured, on the other hand, refers to the sketchingof an outline, which is subsequently detailed to achievethe desired representation. Although no attempt ismade to explain why a shift might occur from theformer to the latter, it is postulated that the motivationis a quest for realism. This quest, in conjunction withgreater skill in visually controlling actions and theability to plan spatially and execute actions, constitutesthe move from a juvenile to a more adult approach todrawing. Obviously such assumptions require furtherinvestigation.

There has been little advance on the seminal work ofauthors such as Luquet (1927) and Kellogg (1969)when considering the maturation of children’s draw-ings. These authors considered that children betweenthe ages of 2 and 3 years make scribbling marks onpaper with no representational intent. The fascinationis thought to be more with the process of experimenta-tion and exploration of media than with an intendedproduct. The drawing by a 21⁄2-year-old child in Figure11-2 demonstrates how repetitious marks (in this case


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circular) are employed in exploring the use of a drawingimplement on paper. Only at the completion of thesemarks is a border introduced as a way of demarcation.Demarcating parts of a picture is argued to indicate thebeginning of an interpretive phase, which occursbetween the ages of 3 and 4 years. During this phase achild begins to interpret a drawing, but generally onlyafter it has been produced. The representational intentis not there at the outset. For example, Figure 11-3 wasdrawn by a 31⁄2-year-old child. The task commencedwith the scribbling at the top of the page with noapparent commitment as to the topic of the drawing.At the completion of the task the child was asked to talkabout what had been drawn. The child nominated thedescriptions that have been inserted in print but onlyafter some reflection and consideration.

In the next stage (4 to 5 years) the nature of thedrawing is announced before its commencement, butthe coordination of individual elements remains diffi-cult. At this stage children label and sign their drawings(Devlin-Gascard, 1997). Words are incomplete andletters are often reversed, but the comprehension ofsymbol and meaning is observable. The drawing of aship by a 41⁄2-year-old boy in Figure 11-4 demonstratesthe use of word labels to describe the intent of thedrawing. In this case it was to inform the viewer thatthe drawing was of the ship Oronsay, which had hit arock and was badly damaged.

The 6- to 7-year-old child is able to include all thecharacteristics of objects being drawn as they areknown to him or her. This is not always consistent with

the way they are in an adult reality. Figure 11-5 demon-strates how a 6-year-old girl perceives her school. Thedrawing is not a realistic representation but it doescontain features of her school and it highlights herunderstanding of a friendly environment. Finally, fromaround 8 years of age the child begins to take intoaccount visual perspective; object position and orienta-tion also become more important. This shift representsa progression from intellectual realism, in which thechild draws what he or she knows about a stimulus, toa stage in which the drawing depicts what actually canbe seen (Laws & Lawrence, 2001). This shift also hasbeen associated with an increase in the amount ofattention given to the object being drawn (Sutton &Rose, 1998), suggesting that realism is based on abilityto attend to detail.

The ability to produce and appreciate graphic per-spective has received considerable attention (Freeman,1980; Freeman, Eiser, & Sayers, 1977; Nicholls &Kennedy, 1992; Toomela, 1999). Some authors see theonset of perspective as evidence of cognitive maturation(Reid & Sheffield, 1990), whereas others argue that itis necessary to learn the rules about how to representsomething in true perspective (Hagen, 1985; Orde,1997). This latter view is based on studies that foundlittle difference between the way in which childrenhandle the three-dimensional plane and the methodsadopted by adults. In both populations, individualswho have no special artistic talent or training reproducethe visual structures that they see in natural perspectivealong a continuum from orthogonal (no diminishing


Figure 11-2 Scribbling marks with no representational intent (21⁄2-year-old boy).

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Rain

Big tree

Driver

JeepBaby inback seat

Horse float

Road

Horse 1

Figure 11-3 Beginning of interpretive phase. Naming occurs verbally at completion (31⁄2-year-old boy).

Figure 11-4 Labels incorporated into picture as a way of demonstrating intent (41⁄2-year-old boy).

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projected size with increasing distance) to projective(image size decreases as distance increases). As withother skills that have learned elements, Messaris (1994)argues that enhancement of depth perception mightlead to a more general stimulation of the capacity forperceiving and thinking about three-dimensional space,an important component of general intelligence.Figure 11-6 demonstrates the use of foreground andbackground, as well as three-dimensional perspective.

Some uniformity exists in the way certain objects aredrawn. Both convention and handedness have beenimplicated in this uniformity (van Sommers, 1984). For example, right-handed people tend to commence

the drawing of a free-standing circle at around the 12 o’clock position and invariably draw counter-clockwise, whereas a little more than 60% of left-handed people draw a circle in a clockwise direction.Another interesting convention is the direction inwhich profiles are facing. Most profiles of faces, forinstance, are drawn turned to the left, as are most cars.Glasses are drawn with the lenses to the left, pencilshave points to the left, spoons and pipes have bowls tothe left. On the other hand, most flags are drawn flyingto the right, and cups and buckets have their handles tothe right. The foundations for these uniformities havenot been documented and neither have there been


Figure 11-5 Objects drawn as perceived, not necessarily realistically (6-year-old girl).

Figure 11-6 Use of foreground and background, as well as three-dimensional perspective (8-year-old boy).

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any reports located that explore the impact of lefthandedness on these tendencies.

Children maintain individuality in their drawings ofthe most common objects even though they may haveconstant access to other children’s drawings. Whenchildren do adopt stereotyped formulas, they frequentlyinclude their own versions alongside. The drawings ofone child over time may be very repetitious in the treat-ment of the same subject material (van Sommers, 1984).The logic is that flexibility of drawing is lost because ofthe repetition of early drawing strategies. This is not to say that children’s drawings never change but thatthey evolve by gradually modifying existing drawingstrategies, rather than by a revolutionary rethinking oftheir basic representational strategy. Following this lineof reasoning, innovation in drawing is thought to occurlate in the sequence of producing a drawing and not inthe initial strokes (van Sommers, 1984).

There has been some discussion in the literatureabout the role of coloring-in and the development ofchildren’s graphic skills (Duncum, 1995). Debateseems to surround the use of coloring-in as a means ofdeveloping pencil control as opposed to being part ofartistic development. Coloring-in, or the use of pencils,crayons, or other implements to provide a color fillwithin a space defined by lines, is widely undertaken bychildren and is promoted by teachers, parents, andcommercial enterprises (King, 1991). For example, it isemployed for the purpose of product promotion formovies and by fast food outlets, and as a means ofkeeping children occupied when they are on planetrips. Further, proficiency of coloring-in is judged andrewarded as part of promotional competitions forvarious products.

Distinction needs to be made about the use ofcoloring-in that is predetermined by the presentation ofa figure and coloring-in that children choose to under-take after they have produced a drawing. The former,which opponents call “dictated art” (Herberholz &Hanson, 1985, p. 5), and place in the same category aspaint-by-numbers, is thought to detract from apprecia-tion of shapes and forms and their creation. Conversely,when children color-in their own creations they aremore highly motivated and better able to adhere to the structures they create (Duncum, 1995). Jefferson(1969) proposed that coloring-in per se can be used asa means of improving fine motor skills associated withhandwriting. This proposition has not been researched;therefore the practice, although widely adopted, seemsto be based in convention more than research.

COMPUTERS AND DRAWING

The production of pictures by young children using thecomputer is now quite a common practice. The

computer mouse is considered the most child-friendlyinterface for accessing a wide range of software (Lane& Ziviani, 1997). The mouse is used in a variety ofways depending on the nature of the program. Therange of tasks required of a mouse to achieve the desiredoutcomes includes tracking, clicking, and dragging(Lane & Ziviani, 1999). As with drawing, producingcomputer graphics makes varying demands on visualmotor control. There have been preliminary attemptsto assess children’s skill proficiency using the mouse(Lane & Denis, 2000) but little documented about thespontaneous attempts of children to draw using acomputer. Figures 11-7 and 11-8 are two examples ofhow children use this medium. The picture in Figure11-7, by a 6-year-old boy, demonstrates many of thecharacteristics thought to manifest in pencil and paperdrawings at this age. There is evidence of spatial realismwith respect to the placement of the bus in relation tothe road and the use of objects (i.e., helicopter) for


BUS JENNY MARKA OWENFigure 11-7 Computer-generated drawingdemonstrating spatial realism (6-year-old boy).

Figure 11-8 Computer-generated freehand drawing (6-year-old girl).

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scenic representation. The mouse functions of tracking,click, drag, and place have been used in this drawing. Inanother example of freehand drawing (see Fig. 11-8), a6-year-old girl demonstrates the use of click and dragto create a self-portrait. There is scope for furtherresearch in this domain to examine comparabilitybetween the production of drawings using pencil andpaper and computer software.

DRAWING AND DEVELOPMENTALEVALUATION

Children’s drawing ability is incorporated into a numberof assessments of developmental status. The ability toreproduce a straight line, a cross, and a circle, forexample, is used in a number of assessments as indicatorsof developmental maturity (Bayley, 1993; Folio &Fewell, 2000; Gesell, 1956; Griffiths, 1970). Further-more one of the most widely used tests of visual-motorintegration, The Developmental Test of Visual MotorIntegration (VMI) (Beery, 1997) evaluates children’saccuracy in reproducing shapes to determine their visual-motor maturity. Some researchers have determinedability in this assessment as being directly related tosubsequent handwriting skill (Oliver, 1990).

A number of studies have associated the ability todraw a human form, such as found in the GoodenoughDraw-A-Man Test (Goodenough, 1926) with a rangeof cognitive (Harris, 1963; Scott, 1981), behavioral(Hartman, 1972; Pope-Grattan, Burnett, & Wolfe,1976), and emotional (Fu, 1981; Roback, 1968) char-acteristics in children. To date the findings from theseinvestigations remain inconclusive. Other issues relatedto the perceptual-motor ability necessary to draw ahuman form, the gender variability in drawings of thisnature, and the efficacy of drawing the self as opposedto a male or female form have been investigated (Short-DeGraff & Holan, 1992). Short-DeGraff and Holanfound that factors in preschool children’s self-drawingwere significantly and positively related to visual motorskills as measured by the Test of Visual Motor Skills(Gardner, 1986) but not with a measure of verbalintelligence. Short-DeGraff and Holan also exploredalternatives to scoring the drawing to those originallyproposed by Goodenough. The high association betweentheir simplified scoring methods and Goodenough’smore complex methods suggests that simplification of scoring criteria is possible. Further research of thescoring criteria, as well as extending the ages of chil-dren under investigation, is warranted based on thesepreliminary findings.

Obviously, for those children with motor impair-ment (e.g., cerebral palsy, spina bifida) the quality ofdrawings may be affected. The differences betweentheir drawings and those of children without disability

should be considered within the context of the child’sperceptual-motor limitations, cognitive impairment, andpossible environmental restrictions. Determining therelative contribution of each factor is not easy. Unfor-tunately, many assessments of developmental and cog-nitive abilities rely, in part, on copying abilities, especiallyfor preschool children (Moore & Law, 1990).

An attempt has been made by Reid and Sheffield(1990) to accommodate perceptual-motor limitationswhen examining children’s drawings. These authorsadopted a cognitive-developmental model for the analysisof drawings in children with myelomeningocele. Reidand Sheffield argue that instead of attending to thequality of drawings, which may be detrimentallyaffected by motor disability, the subject matter and itsdepiction should become the focus for determiningdevelopmental maturity. They propose four complexstages through which children pass in the developmentof mature drawings. Perspective plays an important partof their conceptualization of a mature drawing. Pre-liminary observations suggest that Reid and Sheffield’sstages and conceptualization of the content of drawingsare a useful analytic scheme for children with myelo-meningocele. However, other experimenters argueagainst the developmental significance of perspective(Bremner & Batten, 1991; Hagen, 1985). Furtherresearch to examine the potential clinical utility of Reidand Sheffield’s (1990) findings, especially in the morecomplex final stages of their model, is warranted.

A view of unique developmental progression in thedrawing ability of children with Down’s syndrome hasbeen advanced by Laws and Lawrence (2001). Theyfound preliminary evidence that the spatial charac-teristics of drawings of children with Down’s syndromemay follow an alternative route to those of childrenwithout Down’s syndrome because of problems relatedto motor planning, motor weakness, and aspects oflanguage development. Children with Down’s syn-drome in their study did follow the expected develop-mental, albeit delayed, trajectory of children in thecontrol group. Yet there were elements in the drawingsof children with Down’s syndrome that attested totheir ability to account for aspects such as spatialrelationships, although not in the same way as childrenwithout Down’s syndrome. However, the two groupswere comparable with respect to drawing detail. Theauthors of this study join others (Eames & Cox, 1994)in advocating the use of measures sympathetic tochildren with different developmental profiles.

This section has discussed the development of draw-ing and the expectations of the composition of drawingsfor typically developing children. It has shown the im-portance of considering the different ways that childrenwith special needs may interact with writing imple-ments and develop their drawing competence. The


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following section focuses on a different graphomotorskill, that of handwriting.

HANDWRITING

HANDWRITING AND WRITING:COMPLEMENTARY CONCEPTS

There is an important differentiation, but also relation-ship, between handwriting and writing. Handwritingrefers to the process of transcribing letters to formwords and words to form sentences. Writing, on theother hand, is the composition and content of thematerial that is handwritten. Proficient writing relies on well-developed handwriting skills. Jones andChristensen (1999), for instance, reported thathandwriting skills accounted for 50% of the variance inthe quality of writing content in a sample of 6- and 7-year-old students. Both handwriting and writing arecomplex abilities that are acquired hand-in-hand withchildren’s acquisition of language. As with drawing, thefoundations for both handwriting and writing are theintegration of intrinsic and extrinsic factors. Extrinsicfactors involved in handwriting include instruction inhandwriting, the quality and extent of practice under-taken, the requirements of the task, and the materialsused. Intrinsic abilities include orthographic coding,orthographic-motor integration, visual-motor skills, finemotor skills, cognition, linguistic skills, and motivation(Tseng & Chow, 2000). Orthographic coding involvesdeveloping a visual representation of letters and words,knowledge of the process of forming each letter, averbal label for each letter, an accurate representationof the letter’s form in memory and the ability to accessand retrieve this information from memory (Edwards,2003; Jones & Christensen, 1999; Weintraub &Graham, 2000). Orthographic-motor integration is theway in which this letter knowledge can be motoricallytranscribed to form letters and words on paper. Writerswho have poor orthographic coding and ortho-motorintegration, and thus need to attend to the mechanicsof handwriting (e.g., letter formation, spacing, align-ment), have less attention and working memory thatcan be directed to composing written work and spelling,monitoring, and revision of the written work (Edwards,2003; Swanson & Berninger, 1996).

Children’s competence in writing depends, in part,on the mastery of handwriting (Graham, Harris, &Fink, 2000). The ability to write legibly and in a timelyfashion is necessary for children to adequately docu-ment their knowledge and learning. Children’s docu-mentation is largely the basis on which their knowledgeacquisition is judged. Research has shown that lower

marks are ascribed to work that is less legible evenwhen the content is the same as more legible work(Graham, Weintraub, & Berninger, 2001). Childrenwith handwriting difficulties may avoid writing, or theeffort involved in the process of handwriting mayimpede the ability to generate text that adequatelyreflects their knowledge. Handwriting difficulties are asignificant problem for educationalists and occupa-tional therapists. Berninger and co-workers (1997), forinstance, identified 202 (29%) at-risk writers out of 685children screened and another study identified 24% ofchildren in a sample of 798 kindergarten and grade 1children as having poor handwriting (Harris & Livesay,1992). Further, a survey of grade 1 to 4 teachers re-ported that 23% of children had handwriting difficulties(Hammerschmidt & Sudsawad, 2004). Handwritingproficiency remains a fundamental educational goaldespite the availability and uptake of computertechnology. The focus of this section is on under-standing handwriting as a basis for intervention.

THE DEVELOPMENTAL NATURE OFHANDWRITING

Several features of handwriting development are con-sistent from both historical and cross-cultural perspec-tives. At least some characteristics of handwriting arelikely to be common across cultures, language, andwritten script (Yochman & Parush, 1998). For example,there is a developmental progression of both speed andlegibility of handwriting with age and a relationshipbetween visuomotor skills and handwriting. Also girlstend to write faster and more legibly than boys and moreboys than girls have handwriting difficulties. Further,about 10% of a population is left handed but left handed-ness is not associated with illegibility or slower speed of handwriting. These relationships have been relativelyconsistent in studies of handwriting of English,Chinese, Hebrew, and Norwegian children (Graham,1998; Karlsdottir, 1996; Tseng & Cermak, 1993;Tseng & Chow, 2000; Yochman & Parush, 1998).

There are also consistent factors that seem tooperate in the development of written script over time:The size of the writing diminishes; letter formation,spacing, and horizontal alignment become moreaccurate, simplified, and standardized; the handwritingmay become abbreviated; and cursive forms evolve withcurves replacing angles and ligatures joining letters(van Sommers, 1991; Yochman & Parush, 1998).Children personalize their own style of handwriting as formal handwriting instruction diminishes. Thepersonalized style generally is faster and more efficient,which may result in a deterioration of letter formationat times. Personalized handwriting tends to become amix of manuscript and cursive letters, which develops


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because it is faster than exclusively manuscript or cur-sive. Mixed handwriting that is predominantly cursive isused relatively less frequently than other forms (cursive,manuscript, or mixed but mostly manuscript). Despitethis, mixed handwriting that is mostly cursive tends toyield more legible handwriting (Graham, 1998).

Integral to the issues of handwriting developmentand understanding the developmental expectations forhandwriting is the question of when young children areready to begin handwriting instruction. A number offactors may be considered here: perceptual readiness,linguistic readiness, and the maturity of pencil control.Beery (1989) argued that young children are not readyto learn handwriting until they can correctly copy thefirst nine forms of the VMI (Beery, 1989) (Box 11-1).Kindergarten children who can copy these forms alsocan copy significantly more letters (Daly, Kelly, &Krauss, 2003; Weil & Cunningham Amundson, 1994)and have better handwriting in grade 1 (Marr &Cermak, 2002) than children who cannot achieve nineforms. Daly demonstrated that 56% of children, whentested in the first quarter of the kindergarten schoolyear, were able to copy these nine forms. This compareswith 88% who copied the nine forms in the middle ofthe kindergarten school year in Weil and CunninghamAmundson’s study. Thus if using the VMI as an indi-cator of handwriting readiness, most typically develop-ing kindergarten children should be ready to succeedwith handwriting instruction in the latter half of thekindergarten school year.

As children develop the skill of handwriting, theirperformance changes both qualitatively and quantita-tively. Handwriting quality and quantity translate, respec-tively, into legibility and speed. How do we judge ifeither or both of these aspects are appropriate for the

child’s chronologic or developmental level and whatfactors constitute handwriting dysfunction? Handwrit-ing difficulties become apparent when children writetoo slowly to record sufficient quantities of work orwhen the written work is difficult to read. For instance,teachers report that failure to read student handwritingwas the most important criteria in determining whethera child had handwriting difficulty (Hammerschmidt &Sudsawad, 2004). Poor handwriters are more likely tohave inadequate closure and line quality of letters, poororientation to the writing line, poor spacing betweenwords and letters within words, and inconsistent sizingof words and of letters within words (Malloy-Miller,Polatajko, & Anstett, 1995).

Although children with handwriting difficulty shouldbe seen within their social and educational contexts,general developmental expectations do exist. One studydocuments the grade level expectations of childrenbetween 7 and 14 years of age in terms of handwritingsize, horizontal alignment, spacing consistency, andletter formation (Ziviani & Elkins, 1984). Drawn froma population of Australian schoolchildren, these datasupport the assumption that letters become more accu-rately formed, spacing becomes more consistent, sizediminishes (more particularly in girls), and handwritingattains better horizontal alignment.

Information about developmental expectations andthe factors contributing to handwriting illegibilityprovide a useful baseline measure for children exposedto similar educational instruction. Ziviani, Hayes, andChant (1990) used the normative data discussedpreviously to help specify the nature of difficultiesexperienced by children with spina bifida who were ableto attend regular schools. Their findings indicated thatspeed, horizontal alignment, and letter formation werethe handwriting characteristics most detrimentallyaffected. Meanwhile, handwriting size fell within twostandard deviations of the normative means, and spacingconsistency often was better than in the normativesample. Such findings are useful in delineating hand-writing dysfunction to target intervention and not justaccepting a global disability.

Handwriting quality appears to be an elusive con-cept to measure despite the development of both globaland detailed handwriting assessments. A review of fre-quently used handwriting tools was written by Federand Majnemer (2003). A global measure such as theTest of Legible Handwriting (TOLH) (Larsen &Hammill, 1989) compares the individual’s performancewith a series of model specimens and the importantconsideration in scoring is overall legibility (Feder &Majnemer, 2003). However, researchers have soughtincreasingly to break down handwriting samples intotheir component parts and over the years a wide varietyof handwriting scales (Amundson, 1995; Phelps,


BOX 11-1

The First Nine Forms of theDevelopmental Test of VisualMotor Integration in Order ofIncreasing Difficulty

1. Vertical line2. Horizontal line3. Circle4. Cross5. Right oblique line6. Square7. Left oblique line8. Oblique cross9. Triangle

Beery KE (1989). The Developmental Test of Visual-MotorIntegration, 3rd rev. Cleveland, OH, Modern CurriculumPress.

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Stempel, & Speck, 1984; Reisman, 1993; Stott, Moyes,& Henderson, 1985; Ziviani & Elkins, 1984) andchecklists (Alston, 1985) have been produced to reflectthis approach. Most of these tools identify characteris-tics considered to contribute to handwriting legibility.

In general, the handwriting characteristics specifiedin these detailed tools can be classified as giving form(letter legibility and formation, size) or spatial align-ment (space between letters and words, alignment withlines) to handwriting. These tools provide a more com-prehensive way of understanding legibility difficultiesthan global handwriting assessments and offer a basisfor designing appropriate remedial interventions.Graham, Weintraub, and Berninger (2001) reportedthat several factors were significantly related to goodoverall text legibility. These factors include letterlegibility, the absence of additional lines or strokesattached to letters, correct within-letter proportions,correct letter formation, and no rotations of letterparts. There are other factors, arguably overlooked,that relate to movement and that contribute to hand-writing legibility (e.g., pressure while handwriting, fre-quency of pen lifts). Of all the elements, individualletter legibility (which incorporates letter formation,proportion, and shaping, and letter identification out ofthe context of a word) is considered the most impor-tant to overall text legibility (Graham et al., 2001;Mojet, 1991).

Handwriting speed is not necessarily related tolegibility; that is, handwriting speed is not predictive oflegibility and vice versa (Wann, 1987; Weintraub &Graham, 1998). There is a trade-off, however, betweenhandwriting speed and legibility when children are

specifically asked to write neatly or quickly. Childrenasked to write neatly, for instance, do so at the expenseof speed; and children’s legibility decreases when askedto write more quickly (Weintraub & Graham, 1998).Authorities differ in terms of expected handwritingspeeds for children at various ages. A summary ispresented in Table 11-1. Most variation in handwritingspeed normative information may be attributed todiffering test instructions (“write normally” versus“write fast”). In appraising handwriting speed tests andtheir relevance to assessing handwriting speed, con-sideration needs to be given to the nature of the textbeing written (whether it is copied or self-generated),the timing of data collection in the school year, andvariation in teaching practices. We know that the speedof handwriting slows and that legibility and the qualityof letter formation decrease over a lengthy handwritingsample in both good and poor handwriters (Dennis &Swinth, 2001; Parush et al., 1998a). Fatigue affectshandwriting; therefore the length of text used to eval-uate handwriting speed and legibility and its relation-ship to everyday writing tasks needs to be considered.

Further work on tests of handwriting speed isnecessary to update and validate findings. Standardizeddata used to evaluate handwriting ability and compareperformance with norms should reflect the child’s cul-tural and educational environment. Teachers’ observa-tions within a peer-appropriate context are critical whendeciding if a child’s performance is within develop-mental expectations. Teachers are accurate in categoriz-ing children with and without handwriting difficultieswhen compared with a standardized assessment ofhandwriting ability (Cornhill & Case-Smith, 1996).


Table 11-1 Reported mean handwriting speed (letters per minute) by school grade

School GradeAuthor 3 4 5 6 7

Groff (1961) 35.1 40.6 49.6

Hamstra-Bletz & Blote (1990) 25 37 47 57 62

Phelps, Stempel, and Speck (1985) 35 46 54 66

Sassoon, Nimmo-Smith, and Wing (1986) 64

Wallen, Bonney, and Lennox (1996) 54.2 57.1 63.8 80.7 94.2

Ziviani and Elkins (1984) 32.6 34.2 38.4 46.1 52.1

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FACTORS CONTRIBUTING TO HANDWRITINGPERFORMANCE

Effective intervention can be planned when the factorsaffecting an individual child’s ability to completelegible and timely handwriting are clearly understood.In addition to changes to handwriting legibility andspeed that occur over time in children’s handwriting,various constraints to handwriting acquisition operateat different stages of development. Berninger andRutberg (1992) suggest that neurodevelopmental con-straints in orthographic coding, fine motor function,and orthographic-motor integration are likely to inter-fere with the rapid automatic production of writtenlanguage in younger children. Later, when mostchildren can automatically write the alphabet and spella set of functional words, the writing process is more probably constrained by verbal working memoryand ability to generate the major units of writtenlanguage—the word, the sentence, or text-level struc-tures. Once proficiency in generating units of languageis achieved, writing can be constrained by cognitiveprocesses such as planning, translating, and revisingwhen composing larger pieces of text.

For older children constraints may still be operatingat the neurodevelopmental or linguistic, as well as thecognitive levels. Inefficiencies in the low-level neuro-developmental processes early in handwriting acquisitioncan contribute to future higher-level writing dis-abilities, both directly (because production of writtenmaterial continues to be a problem) or indirectly(because of an aversion to writing arising from earlyfrustration and failure) (Berninger et al., 1997). Someof the major factors implicated in handwriting perfor-mance follow.

Working MemorySwanson and Berninger (1996) demonstrated thatindividuals have a unique working memory. Workingmemory is the ability to temporarily retain informationduring the processing of other information. Duringhandwriting, orthographic codes are retrieved fromlong-term memory and held in working memory whilethe writer is developing the text (Weintraub & Graham,2000). More processing functions are available for ideageneration, translation, and sequencing of ideas to text,and revision of writing when aspects of handwriting(including orthographic skills and even punctuation)are automatic (Jones & Christensen, 1999). Further,ideas that are held in working memory may be lost if achild needs to focus attention on the mechanics offorming a letter (Graham et al., 2001). Evidence forthis derives from studies that have shown a relationshipbetween orthographic-motor integration and writtenexpression and have demonstrated that writing (written

expression) improved after intervention that specificallytargeted orthographic-motor integration by teachingcorrect and automatic letter formation (Berninger etal., 1997; Graham, Harris, & Fink, 2000; Jones &Christensen, 1999). An essential educational goal is toprovide handwriting instruction that develops automatic,fluent handwriting to free working memory for writing;that is, generating ideas, monitoring, and revising con-tent (Berninger et al., 1997).

Handwriting InstructionHandwriting is heavily influenced by the nature of theinstruction received and the extent of practice under-taken by the individual. In fact, the main factor thatinfluenced legibility in a study by Lamme and Ayris(1983) was the great variability in handwriting instruc-tion provided by the teachers involved in the study.Handwriting probably receives insufficient emphasis inschool curricula: Teachers (62% of sample) reportedthat they would like to spend more classroom time onhandwriting instruction (Hammerschmidt & Sudsawad,2004). Berninger and co-workers (1997) surveyedteachers who reported that students were becomingless proficient at handwriting when they reached year 1than students of previous years.

The importance of focused handwriting instructionto both legible handwriting and writing has beendemonstrated in a number of studies (Berninger et al.,1997; Graham et al., 2000; Jones & Christensen,1999; Jongmans et al., 2003; Karlsdottir, 1996). Im-portant components to include in handwriting instruc-tion are listed in Box 11-2 (Berninger et al., 1997;Graham et al., 2000; Hayes, 1982; Jones & Christensen,1999). It seems that providing more types of cues orperceptual prompting of letter formation may result inbetter outcomes.

Adi-Japha and Freeman (2001) found that by 6years of age children’s writing and drawing systemswere differentiated. Children as young as 3 years of ageproduce different scribbles when asked to write theirname than those scribbles generated when drawing apicture (Haney, 2002). Writing-specific cortical routesemerge probably as a result of practicing handwriting.Writing within a script context (e.g., words and letterson a page) rather than writing within a picture contextproduced more fluent handwriting (Adi-Japha &Freeman, 2001). The importance of handwriting prac-tice in early learners and thus a differentiation andspecialization of writing is reinforced by these findings.Further, consideration needs to be given to the teach-ing and practice of handwriting within writing specificcontexts; that is, using dedicated writing implementsand books, and reducing drawing conditions when theaim is handwriting proficiency. Working within a scriptcontext activates the writing system, and activation of


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the writing processing system separately from a drawingcontext prepares for more accurate and automatichandwriting output.

The outcomes of the studies that have focused ondeveloping orthographic skills and automatic hand-writing have all been positive. The results suggest thatpoor letter knowledge and orthographic skills are majorcontributors to handwriting difficulties and are essentialto consider in handwriting intervention. Other studiesprovide useful information to consider when planninghandwriting intervention. One study examining theability of children in years 1 to 3 to write manuscriptletters reported that some letters were more difficult toform legibly (Graham et al., 2001). Overall theseletters, in descending order of difficulty, were q, z, u, j,k. Fortunately some of these letters are not frequentlyused in handwriting but may require more focus duringhandwriting instruction and should be introduced onlyafter mastery of easier letters. Despite ongoing debate,it seems that teaching slanted or elliptical manuscriptdoes not have advantages over traditional manuscript inlegibility outcomes or assisting the transition to cursivehandwriting (Graham, 1998). Karlsdottir (1996)showed that handwriting quality of older (10-year-old)students was significantly enhanced by reintroducingeach letter form with accompanying visual and verbalcues. Thus one should consider these orthographic fac-tors even in more mature writers. Older writers also tendto personalize handwriting by mixing manuscript andcursive text, among other things. Generally this is to

the advantage of both speed and legibility and need notbe discouraged.

Factors That Influence the Effectiveness ofHandwriting Instruction Factors such as kinesthesis, fine motor skills, and visualmotor abilities are associated with handwriting devel-opment and performance (Weintraub & Graham, 2000).Researchers exploring these factors operate under theassumption that they underlie handwriting performanceand that understanding their relationship with hand-writing assists with developing and evaluating interven-tion programs (Tseng & Cermak, 1993). Further factors,such as posture while handwriting, paper positioning,and stabilization of paper, as well as other ergonomicfactors, discriminate good and poor handwriters (Parush,Levanon-Erez, & Weintraub, 1998b). Posture and sta-bilization anomalies may result from similar mechanismsto those that cause handwriting difficulties. It is not yetknown whether remediating kinesthesis, fine motor,visual motor, ergonomic, and other factors improvehandwriting output and writing outcomes.

Issues in relation to motor execution specific tohandwriting were introduced in the earlier section onthe processes of acquisition of graphomotor skills andare expanded here. When an orthographic code ismobilized from memory for handwriting, a motorprogram is executed that encompasses manipulating a writing implement to form letters and words(Weintraub & Graham, 2000). Two aspects of motorexecution are examined in the literature, fine motorskills (including in-hand manipulation) and abilitiesrelated to kinesthesis.

Isolated and graded finger movements are necessaryto provide precise and rapid manipulation of a writingtool for handwriting. On the basis of this premise, finemotor skills and in-hand manipulation are frequentlyassessed as part of a handwriting assessment. Fine motorskills are assessed globally by tools such as the PeabodyDevelopmental Motor Scales—Fine Motor (Folio &Fewell 2000). Fine motor skills incorporate the basicpatterns of reach, grasp and release, and the more com-plex skills of in-hand manipulation and bilateral handuse (Exner, 1989). In-hand manipulation, then, is anessential component of dexterous hand function andcan be assessed separately using tools such as those de-veloped by Exner (1993) or Case-Smith (1995). Theseassessments include some of the defined features of in-hand manipulations such as rotation (e.g., turningan object over using the fingers of one hand) andtranslation (e.g., using the fingers of one hand to moveobjects in and out of the palm). In-hand manipulationis assessed as its own entity in handwriting evaluationbecause of a perceived relationship to pencil manipula-tion. In reality the association between fine motor skills


BOX 11-2 Important Components to Includein Handwriting Instruction

• Copying model letters• Visual directional cues provided by arrows• Verbal prompting of letter formation (both instruc-

tor and self-verbal prompting)• Copying from memory• Reinforcing letter names and practice of letters with

a focus on committing these to memory

Berninger VW, Vaughan KB, Abbott RD, Abbott SP,Rogan LW, Brooks A, Reed E, Graham S (1997).Treatment of handwriting problems in beginning writers:Transfer from handwriting to composition. Journal ofEducational Psychology, 89(4):652–656; Graham S, HarrisKR, Fink B (2000). Is handwriting causally related tolearning to write? Treatment of handwriting problems inbeginning writers. Journal of Educational Psychology,92(4):620–633; Hayes D (1982). Handwriting practice:The effects of perceptual prompts. Journal of EducationalResearch, 75(31):169–172; Jones D, Christensen CA(1999). Relationship between automaticity in handwritingand students’ ability to generate written text. Journal ofEducational Psychology, 91(1):44–49.

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or in-hand manipulation and pencil grip and hand-writing speed and legibility has not been extensivelyexplored. Rubin and Henderson (1982) found thatchildren with poor handwriting did not have signifi-cantly different scores from a group of good hand-writers on the Test of Motor Impairment, but they didhave more variability of their scores. Tseng and Chow(2000) on the other hand, found that Chinese hand-writers, categorized as slow writers by their teachers,had significantly lower scores on the Upper LimbSpeed and Dexterity subtest of the Bruininks-OseretskyTest of Motor Proficiency than normal speed hand-writers. Cornhill and Case-Smith’s work (1996) pro-vides us with some evidence that in-hand manipulationis a significant predictor of handwriting legibility. Theirsample of year 1 students with handwriting difficultieshad significantly lower in-hand manipulation scoresthan fellow students with good handwriting. Still we donot know whether improving fine motor and in-handmanipulation ability results in more legible or fasterhandwriting.

Debate continues about the role of kinesthesis inhandwriting performance and the effectiveness ofkinesthetic training in improving handwriting. Laszloand Bairstow (1985b) have argued, based on theirwork with the KST, that kinesthetic memory, morethan kinesthetic acuity, is primarily responsible for theskilled performance of writers. Studies investigating theproposed relationship between training children usingthe testing equipment of the KST and handwritingperformance have reported contradictory findings andhave cast a shadow on the psychometric properties ofthe KST (Hoare & Larkin, 1991; Lord & Hulme,1987). Two of the stronger studies provide the bestevidence that the KST is not associated with hand-writing. Copley and Ziviani (1990) found no significantrelationship between the KST and handwriting qualitywhen testing good and poor handwriters. A well-designed randomized controlled trial evaluated hand-writing outcomes after kinesthetic training on the KSTequipment (Sudsawad et al., 2002). There were nosignificant between-group differences in these grade 1children after kinesthetic training compared with asham intervention and no intervention. Previous studieshave evaluated kinesthetic training in children withpoor handwriting without identifying whether or notthey had kinesthetic difficulties. An important differ-ence of Sudsawad’s study from previous ones is that the children recruited were identified as having hand-writing difficulty, as well as kinesthetic impairmentidentified by the KST. The evidence suggests that kines-thetic training using the KST equipment is not aneffective handwriting intervention.

Research on other aspects of somatosensory abilityand handwriting are inconclusive. Weintraub and Graham

(2000) found that “finger function” was a strong pre-dictor of good or poor handwriting ability. Rather thanreflecting strictly fine motor ability, the finger functiontasks contained largely proprioceptive and somato-sensory ability. Yochman and Parush (1998), however,found no correlation between kinesthesia-related testsand handwriting performance.

Visual motor integration appears to be an importantfactor in handwriting legibility. A great deal of researchsupports the assumptions that (a) visual motor inte-gration is correlated with handwriting performance ingood, as well as poor handwriters (Tseng & Chow,2000; Tseng & Murray, 1994; Weil & CunninghamAmundson, 1994); (b) visual motor abilities are weakerin children with handwriting difficulties, across a widerange of ages, compared with children without hand-writing difficulties (Cornhill & Case-Smith, 1996; Daly,Kelly, & Krauss, 2003; Rubin & Henderson, 1982;Tseng & Chow, 2000; Tseng & Murray, 1994); and (c) visual motor integration difficulties are a predictorof handwriting legibility (Cornhill & Case-Smith, 1996;Maeland, 1992; Tseng & Chow, 2000; Weintraub &Graham, 2000; Yochman & Parush, 1998). Visual motorintegration may be particularly important in the acqui-sition of handwriting because visual motor abilities areused to acquire orthographic coding skills. Occupationaltherapists tend to view visual motor integration as under-lying handwriting dysfunction and intervene using visualmotor activities (Case-Smith, 2002). Despite this relativeabundance of evidence confirming the relationshipsbetween visual motor integration and handwriting,there is as yet no evidence that remediating visualmotor skills will result in enhanced handwriting output.

Handwriting intervention studies in the educationaland motor learning literature focus on developingorthographic coding and using self-instruction methodsfor enhancing handwriting legibility and writing ability(Berninger et al., 1997; Graham et al., 2000; Hayes,1982; Jones & Christensen, 1999; Jongmans et al., 2003;Karlsdottir, 1996). These studies provide good evidencethat these approaches are effective in enhancing variousaspects of handwriting legibility and speed and also thecontent of written work. Studies in occupational therapyare fewer in number than studies in education. Typicallyoccupational therapy intervention studies integratemultiple theoretical perspectives and offer broad-basedinterventions encompassing biomechanical, multisensory,visual motor, fine motor, and handwriting-specific inter-ventions (Case-Smith, 2002; Lockhart & Law, 1994;Peterson & Nelson, 2003). A range of outcomes whichare not always related to handwriting legibility, speed, andcontent are evaluated. Two such broad-based studies(including one randomized controlled trial) reportedsignificant improvement in handwriting; however, thespecific components of the intervention that contributed


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to the outcomes are undetermined (Case-Smith, 2002;Peterson & Nelson, 2003).

COMPUTERS AND HANDWRITING

Children with significant disability or those who con-tinue to have handwriting difficulties even after inter-vention may consider word processing as an alternative.There are a multitude of factors to consider in decidingwhether keyboarding is an appropriate strategy forchildren to adopt. Just some of these factors are thekeyboard configuration (e.g., laptop, PC); software(e.g., word prediction); transfer of data among home,school, and printers; the cognitive demands of man-aging files, academic subjects, and the facilities of mul-tiple software packages; the physical demands of thetask; and the suitability to the child. Further, it isnecessary to predict whether a child will actually achievequality written expression with adequate accuracy andspeed compared with handwriting.

Keyboarding, like handwriting, is a complex skill andrequires many hours of practice to achieve proficiency.Learners of keyboarding should progress throughstages of learning the position of keys and the variousmovement patterns necessary to achieve correct keystrokes. Proficiency, which relies largely on kinestheticfeedback and little on visual feedback, may be achievedwith practice. It is interesting to contemplate whetherhandwriting and keyboarding have similar underlyingabilities. If so, and if handwriting is a difficulty, thenthese same underlying abilities also may affect thedevelopment of proficiency at keyboarding. Studiesindicate that different components underlie hand-writing and keyboarding accuracy in typically develop-ing students (Preminger, Weiss, & Weintraub, 2004;Rogers & Case-Smith, 2002). This information com-bined with Barrera, Rule, and Diemart’s (2001) findingthat year 1 students wrote more words and sentencesusing a keyboard than handwriting gives us more con-fidence in using keyboarding as an option for childrenwith handwriting difficulties.

Word processing and word prediction software canincrease the legibility and spelling of written work inchildren with learning and handwriting difficulties(Handley-More et al., 2003). Studies do not concur asto whether keyboard instruction can result in keyboardspeeds that are faster than handwriting (Rogers &Case-Smith, 2002). Indeterminate hours are spentlearning and refining handwriting. The expectationshould be that substantial effort goes into ensuring thatthe speed and accuracy of keyboarding is at least equi-valent to handwriting to make it a viable alternative tohandwriting. The secondary complications of poor hand-writing (e.g., compositional difficulties, avoidance ofhandwriting, and loss of confidence) may be avoided if

children can be offered word processing as a viableoption to handwriting at an appropriate time (Rogers& Case-Smith, 2002).

This review of handwriting has discussed hand-writing development and factors associated with skilledhandwriting execution. The fact that handwriting under-lies quality written output and thus that good hand-writing instruction is essential has been emphasized.

SUMMARY

The process and products of children’s drawing andhandwriting have intrigued occupational therapists, aswell as others interested in child development, for anumber of years. It is clear from this chapter that,although we now have certain structures in place tounderstand the developmental transitions in children’sdrawings, there is still much to understand. The samecan be said for handwriting. There remain aspects ofdrawing and handwriting acquisition that still tantalize;this chapter concludes by pointing to some issues thatstill beg investigation.

Drawing is an important developmental experiencefor children. With the increasing use of computers byyounger and younger children, some of the pencil andpaper drawings with which we are most familiar arebeing accomplished using a computer. Are we able totranslate our knowledge of paper-based outcomes tothose on the screen?

Preliminary research has indicated that handwritingand keyboarding have differing underlying compo-nents. Thus we are unlikely to be able to translate ourknowledge of handwriting directly to keyboarding. Agreater understanding of word processing, as analternative form of recording work, is necessary tomatch it to the individual needs of students. Using amotor learning framework, we understand that hand-writing is a learned motor task requiring interplayamong the writer, the task, and the environment. A keyenvironmental factor in its acquisition is the quality ofinstruction received and amount of practice under-taken. However, even in the presence of adequateinstruction there are a multitude of factors pertinent toan individual that may affect the child’s ability todevelop handwriting. The association between some of these factors and handwriting has been betterresearched than others. For example, we know there isan association between visual motor integration andhandwriting. We are less certain of the relationshipbetween other factors such as kinesthesia and in-handmanipulation and handwriting. Cognitive, linguistic,and motivation factors also should inform research inthis field. We require a better understanding of the


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relationship of all these factors to handwriting andespecially how these factors are manifesting in childrenwith poor handwriting. It may be that a breakdown inany of these factors may impede a child’s acquisition ofhandwriting. Determining their relative effect onperformance is essential if appropriate intervention is tobe designed.

Developing proficient handwriting requires childrento learn and apply a number of rules, as well as todevelop motor programs for the efficient execution ofscript. We have established that the nature and extentof instruction are highly influential in proficienthandwriting output. Part of handwriting instruction isknowing how to form individual letters and join themto manufacture words. One area that has not receivedmuch attention in the literature is the influence of dif-ferent scripts in the attainment of proficient hand-writing. The relative merits of learning print (ball andstick) and then moving on to learn cursive handwriting,as opposed to starting with a simple modified cursivescript, also requires further investigation. Bothapproaches, in fact, are currently used in school systemsthroughout the world. We simply do not know whichis more effective in optimizing handwriting develop-ment and outcomes.

Research in the area of implement grasp andmanipulation suggests that the type of grip being usedneed not necessarily impede handwriting speed andlegibility (Dennis & Swinth, 2001; Koziatek & Powell,2003). This suggests that the mechanism for executionof handwriting is less important than the cognitive,perceptual, and planning components. Research isneeded to clarify this relationship.

This review of the development of drawing andhandwriting shows a field dotted with light and shade.Our knowledge of drawing and handwriting, groundedin research and founded on principles of motorlearning, is the “light” we shed on our interactions withchildren with handwriting difficulties. The “shade”relates to areas in which knowledge is sparse. Weshould continue to seek knowledge that will shed lighton the many “shaded” areas that currently exist in thisarea and will enable us to provide evidence-based andeffective intervention for our clients.

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