Standardized tests of handwriting readiness: a systematic review of the literature
Margo J van Hartingsveldt at Department of Rehabilitation, Occupational Therapy 898, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands. E-mail: email@example.com
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.
Activities of daily living
- Beery VMI
Beery Developmental Test of Visual Motor Integration
Bruininks–Oseretsky Test of Motor Proficiency, 2nd edition
Cumulative Index to Nursing and Allied Health Literature
Draw-A-Person: Quantitative Scoring System
Denver Developmental Screenings Test, 2nd edition
Education Resources Information Center
Maastricht’s Motor Test
Motor Performance Checklist
Movement Assessment Battery for Children, 2nd edition
Nine Hole Peg Test
Scale of Children’s Readiness in Printing
School Assessment of Motor and Process Skills
Taxonomic Code of Occupational Performance
Test of In-Hand Manipulation–revised
Writing Essential Skill Screener–Preschool version
What this paper adds
- • An overview of tests that assess aspects of writing readiness in 5- and 6-year-old children.
- • An overview of the content, feasibility, and psychometric properties of 12 tests that assess aspects of writing readiness.
- • The importance of assessment in the context of a child’s natural classroom setting.
Competent handwriting is one of the most important skills that children learn during their first years at school.1,2 Handwriting is a major occupation in childhood that is essential for the child’s participation in the classroom environment.3 Thirty to sixty percent of the school day is devoted to fine motor activities, with writing as the predominant task.4,5 The prevalence of handwriting problems has been estimated to range between 5% and 27% depending on grade, selection criteria, and assessment instruments used.6–10
The transition from kindergarten to elementary school is an important period of childhood. Early school success and positive transition tends to translate into higher levels of social competence and academic achievement that remain stable over time.11–13 Reducing the problems in pre-writing skills in kindergarten children is crucial: research has shown that a child’s healthy adjustment to school during these first years is a precursor to subsequent school success.14–16 Educators and paediatric therapists attempt to identify children who are at risk of writing problems at an early age in order to provide additional instruction or therapeutic intervention.13,14,17 Kindergarten children are often referred to occupational or physical therapists for evaluation and/or treatment of poor fine motor performance, including difficulty with pre-writing skills. Therapy referrals made early in a child’s academic career are considered to be beneficial to the child so that a deficit can be addressed – and hopefully corrected – before the student’s academic performance is affected.18 In their review on handwriting remediation studies, Feder and Majnemer19 concluded that most studies on handwriting remediation provide evidence to support its effectiveness despite variations in the duration, frequency, and treatment approaches applied.
The negative effects of handwriting difficulties on a child’s academic performance and self-esteem, as discussed in the literature,14,17,20 make early evaluation of pre-writing skills of major importance. Such early evaluations provide the kindergarten teacher with the opportunity to stimulate paper-and-pencil tasks and, if major problems in pre-writing skills are identified, to refer the child to a paediatric occupational or physical therapist.
A recent trend in occupational therapy is to focus assessment on real-life situations, making the performance assessment contextual and meaningful.21 The strong shift to adopt an occupation-based approach in the assessment of children is based on the paradigm that the evaluation should determine how children participate in occupations in a relevant context.22 Therefore, pre-writing activities should be assessed in the natural school setting of the child where the influence of the environment can be taken into account. Subsequent analyses of the assessment results can then consider how environmental features support performance or create barriers. Each child reacts differently to environmental variables; what might support performance in one child can be a barrier to performance in another.23
In paediatric occupational therapy the focus of the intervention is on daily occupations in play, activities of daily living (ADL), and school. In occupational therapy, occupations are defined as a set of activities meaningful to the child in a specific context; the activities comprise a set of tasks, and the tasks consist of a set of performance components. This hierarchy is based on the Taxonomic Code of Occupational Performance (TCOP).24,25 According to the TCOP, handwriting readiness can be assessed at the level of occupations, activities, tasks, and performance components (Table I).
Table I. Levels of occupation-based assessment
|Occupation||An activity or set of activities that is given meaning by individuals in a specific context||Writing own name in the classroom|
|Activity||A set of tasks||‘Drawing’ the letters on a paper|
|Task||A set of functions||Grasping and positioning the pencil in the hand|
|Performance components||Perceptual-motor function||Fine motor coordination, visual motor integration|
Next to occupation, at the level of activities and tasks, an assessment of writing readiness should contain an observation of ergonomic factors, such as body position and pencil grip. Parush et al.26 noted that children who had poor handwriting had an inferior pencil grip paper and body positioning compared with children with good handwriting. Rosenblum et al.27 described a high correlation between body position and the fluency of handwriting. Subsequent studies, however, found that that grip affected neither legibility28 nor the undertaking of writing long passages,29 although these studies did not take into account the dynamic aspect of the adopted grips.30 Kindergarten is an important period for the development of wrist stabilization in extension position and a dynamic pencil grasp. Between the ages of 3 and 6 years, most children develop from a transitional static grasp with wrist movements to a mature dynamic grasp with thumb and finger movements.31 Information about pencil grip and the position of the wrist and the forearm resting on the surface has to be evaluated because of early remediation. This is important to prevent correction of the inefficient wrist position and grip after it has been reinforced and kinesthetically locked in. At the level of performance components, empirical evidence suggests that problems in handwriting relate to a deficit in perceptual–motor function. The motor and perceptual components related to poor handwriting performance may include fine motor control, visual motor integration, visual perception, kinesthesia, and sensory modalities.19,32 Feder and Majnemer19 state in their review that the correlation between visual perception, kinesthesia and sensory awareness of the fingers with handwriting remains unclear. On the other hand, there is evidence for a correlation between fine motor control, visual motor integration, and handwriting. Several studies have found that children with handwriting problems show a deficit in fine motor control,7,8,32,33 whereas in other studies, visual motor integration was found to contribute significantly to poor handwriting.5,7,32,34,35 Volman et al., in their study of 29 children in grades 2 and 3 with handwriting problems and 20 children without handwriting problems, support the concept that there are two different mechanisms underlying the quality of handwriting in children: fine motor coordination and visual motor integration. The findings of this study suggest that the screening of the performance components of writing skills in kindergarten children should focus on these two underlying mechanisms.6
In the Netherlands, a valid and reliable occupation-based assessment for writing readiness among kindergarten children is lacking. The aim of this systematic literature review was to investigate whether there are psychometric sound tests or test items to assess handwriting readiness in 5- and 6-year-old kindergarten children at the level of occupations, activities/tasks and performance components.
In November 2009 we undertook a comprehensive search of computerized bibliographic databases, including Pubmed (1966–November 2009), Cumulative Index to Nursing and Allied Health Literature WebSPIRS (CINAHL; 1982–November 2009), PsychINFO WebSPIRS (1966–November 2009) and Education Resources Information Center WebSPIRS (ERIC; 1966–November 2009). Our broad search strategy included Medical Subject Headings (MeSH) or indexed terms as well as free-text words for ‘standardized measurements’ AND ‘kindergarten children of 5 and 6 years old’ AND ‘school occupations’ OR ‘school activities’ OR ‘paper-and-pencil tasks’ AND performance components, such as ‘fine motor coordination’ OR ‘visual motor integration’ (Table SI, published online). Because we conducted a comprehensive review, with the purpose of finding as many references to different tests or test items as possible, we included all study designs, such as psychometric articles and intervention studies. The names of identified instruments were used as terms for a further search of the electronic databases. Additional potentially relevant publications were searched manually through citation and author tracking.
Inclusion and exclusion criteria
Tests or test items were included in the review if they met all of the following criteria: (1) participants are kindergarten children aged 5 and 6 years, (2) handwriting-readiness specific (i.e. items on school occupations, school activities, paper-and-pencil tasks, fine motor coordination, and visual motor integration), and (3) a standardized measurement was mentioned in the publication. Tests or test items were excluded if they were not published in English, German, or Dutch and did not meet the inclusion criteria.
A preliminary selection, based on title and abstract, was performed independently by two of the reviewers (MvH, PA). Where there was disagreement, a decision was reached by consensus of the reviewers. Full-text articles that fit the inclusion criteria were retrieved for more detailed evaluation by the first author. Tests or test items were included after agreement by both raters, and conflicting viewpoints were discussed until agreement was reached. Assessment manuals were sourced, and a further electronic search was undertaken for included measures.
Criteria for evaluating psychometric properties of handwriting readiness measures
The quality criteria of Terwee et al.36 were used to assess the psychometric properties of the instruments. For each property, a sample size of at least 50 participants is considered adequate. In our study, we evaluated the following psychometric properties of an instrument.
A positive rating was given when factor analysis was applied and Cronbach’s alpha was between 0.70 and 0.95.
A positive rating was given if a clear description was provided of the measurement aim, the target population, the concepts that were measured, and the item selection. In addition, the target population should have been involved during item selection.
A positive rating was given if convincing arguments were presented that the criterion standard was at least 0.70.
A positive rating was given when hypotheses were specified in advance, and at least 75% of the results were in agreement with these hypotheses.
A positive rating was given when the smallest detectable change or the limits of agreement were smaller than the minimal important change. Because this is a relatively new approach, a positive rating was also given if authors provided convincing arguments that the agreement was acceptable.
A positive rating was given when the intraclass correlation coefficient (ICC) or the weighted kappa was at least 0.70.
A positive rating was given if hypotheses were given in advance and at least 75% of the results were in accordance with the hypotheses, and if the minimal important change was greater than the smallest detectable change.
The criteria of Terwee et al.36 are based on classical psychometric testing. These do not include Rasch analysis, a method that has recently become very popular in psychometric research; therefore, this analysis was added to the reliability and validity items of the Terwee et al.36 criteria. In addition to these established psychometric properties36 the presence of normative scores are of importance to determine whether a score reflects normal or abnormal behaviour.
Selection of assessment tools
The search resulted in 1316 citations (Fig. S1, published online). Duplicates were removed, narrowing the pool to 1114 citations. The preliminary selection, based on the abstracts, contained 70 citations, with information about standardized tests on school-occupations, paper-and-pencil activities/tasks, fine motor coordination, and visual motor integration in kindergarten children aged 5 and 6 years.
We were unable to retrieve 11 articles via the university library, and seven of the 70 citations were dissertation reports; consequently, the preliminary selection was reduced to 52 full-text articles. Of these 52 articles, 26 were excluded because information about a test was lacking (five articles), the test included was not standardized (three articles), the test was not handwriting-readiness specific (14 articles), or the participants were older than 6 years (four articles). Citation and author tracking resulted in an additional 14 articles being retrieved and three manuals of included tests.37–39 The final selection consisted of a total of 40 articles which included information about standardized assessments on writing readiness in kindergarten children aged 5 and 6 years. We found 12 tests that assess aspects of handwriting readiness in this age group. The included measurements were (1) School Assessment of Motor and Process Skills (School-AMPS); (2) Scale of Children’s Readiness in Printing (SCRIPT); (3) Writing Essential Skill Screener–Preschool version (WESS-P); (4) Test of In-Hand Manipulation–revised (TIHM-R); (5) Nine Hole Peg Test (9HPT); (6) Beery Developmental Test of Visual Motor Integration (Beery VMI); (7) Draw-A-Person: Quantitative Scoring System (DAP:QSS); (8) Motor Performance Checklist (MPC); (9) Movement Assessment Battery for Children, 2nd edition (M-ABC-2); (10) Maastricht’s Motor Test (MMT); (11) Bruininks–Oseretsky Test of Motor Proficiency, 2nd edition (BOT-2); and (12) the Denver Developmental Screenings Test, 2nd edition (Denver-II). We found information about the first and second editions of the M-ABC and BOT. We have chosen to include the second edition of these tests in this review.
These 12 assessment tools were grouped according to target population, objective, subscales, number of items (total and handwriting-readiness specific), number of response options, time to administer, required course, required materials, and citations in Pubmed, PsychINFO, CINAHL, and ERIC (Table II).
Table II. Classification of tests that assess aspects of handwriting readiness in 5- and 6-year-old kindergarten children
|Scale of Children’s Readiness in Printing (SCRIPT)17,18,50||Kindergarten children||Measure a child’s ability to copy manuscript alphabet letters||Only one||34 (34)||0/1|| ||No||Test booklet and pencil||5||0||4|
|Beery Developmental Test for Visual Motor Integration (Beery VMI)1,17,19,44,48,56||2–18y||Screen for visual motor deficits that can lead to learning, neuropsychological, and behavior problems||Visual motor integration. Visual perception. Motor coordination||90 (90)||0/1||25||No||Test booklets and pencil||262||38||49|
|Test of In-hand Manipulation–Revised (THIM-R)50–52|| ||Measure a child’s ability of in-hand manipulation skills (translation and rotation)||Only one||3 (3)||Timed task||10||No||Pegboard||2||1||5|
|Bruininks–Oseretsky Test of Motor Proficiency, 2nd edition (BOT-2)65,81,82||4–21y||An individually administered measure of gross and fine motor skills||Fine manual control. Manual coordination. Body coordination. Strength and agility||53 (20)|| ||45–60||No||Testkit||4||79||109|
|Movement Assessment Battery for Children, 2nd edition (M- ABC-2)60,61||3–16y||Identifies, describes, and guides treatment of motor impairment||Manual dexterity. Ball manipulation skills. Static and dynamic equilibrium||8 (3)||6-point rating scale||20–40||No||Testkit||124||86||179|
|School Version of the Assessment of motor and Process Skills (School-AMPS)40,83||3–12y||Evaluation tool for measuring student’s schoolwork task performance in typical classroom settings||Pen/pencil writing tasks. Drawing and coloring tasks. Cutting and pasting tasks. Computer writing tasks. Manipulative tasks||2 (2)||4-point rating scale||60–80||1wk course||Test booklet and pencil||7||6||4|
|Motor Performance Checklist (MPC)58,59||5y||Screening for gross and fine motor problems||Only one||12 (3)||0/1||5||No||Checklist and pencil||1||0||2|
|Draw A Person: Quantitative Scoring System (DAP:QSS)42–46||3–15y||Measure of mental ability||Only one||1 (1)||Counting body parts||15||No||Paper, pencil, test booklet||1034||17||181|
|Denver Developmental Screenings Test–2nd edition (Denver II)67,68||0–6y||A screening tool designed for children at risk of developmental problems||Gross motor. Language. Fine motor–adaptive. Personal–social||125 (28)||0/1||20–30||No||Checklist, interview, observation||32||62||352|
|Writing Essential Skill Screener–Preschool version (WESS-P)49||4–5y||Screening for preschool writing skills|| || || || || || ||1||0||0|
|Nine Hole Peg Test (9HPT)55,84||5–11y||Measures fine motor dexterity||Only one||1 (1)||Timed task||5||No||Pegboard with 9 pegs||24||117||122|
|Maastricht’s Motor Test (MMT)62||5–6y||Objectify qualitative and quantitative aspects of movement||Static balance. Dynamic balance. Diadochokinesis. Manual dexterity.||70 (28)||3-point rating scale||30||No||Computer test booklet||1||0||1|
Characteristics of assessment tools
The 12 instruments were grouped according to the TCOP24,25 at the level of occupation, activities/tasks, and performance components (Table III).
Results classified on level of occupation according to the Taxonomic Code of Occupational Performance (TCOP)24,25
There is only one occupation-based test that assesses the aspects of handwriting readiness on the different levels of the TCOP. The School-AMPS examines the interaction between a student, a schoolwork task and a classroom environment and evaluates the quality of the student’s schoolwork task performance, measured at the level of complex activity and occupation. Motor and process components of schoolwork performance are evaluated by an occupational therapist through observation in the classroom setting.40,41 From the performance components perspective, only the aspect of fine motor coordination is assessed.
There are two instruments that involve one single paper–and-pencil task: the SCRIPT17,18 and the DAP:QSS.42–47 The SCRIPT is a letter shape copying test developed for kindergarten children.48 The child has to copy all 26 lowercase letters and eight uppercase letters, namely, A, K, M, N, V, W, Y, and Z. The DAP:QSS is a figure drawing assessment with a quantitative scoring system.
One instrument was found that evaluates writing readiness at the level of paper-and-pencil tasks and visual motor integration: the WESS-P.49 The WESS-P consists of four activities reflecting pre-writing skills and conceptual development and includes copying simple geometric shapes, copying speed, copying letters and numbers, and name writing.
Fine motor coordination
Two instruments were found that consist only of a fine motor coordination task: the TIHM-R50–53,53,54 and the 9HPT.55 Both tests use a time procedure with pegboard and pegs. In the TIHM-R, the pegs must be used in in-hand manipulation tasks, such as translation and rotation with stabilization; in the NHPT, the pegs must be used in a one-handed aiming task.
Visual motor integration
One test for the assessment of visual motor integration for this population was found: the Beery VMI.1,17,19,44,48,56,57
General motor tests
Five general motor tests designed to measure fine and gross motor skills in children were found: The MPC,58,59 M-ABC-2,60,61 MMT,62 BOT-21,2,5,63–65,65,66 and Denver II.67,68 These tests evaluate fine and gross motor skills and include items of writing readiness.
Psychometric properties of assessment tools
The psychometric properties for these 12 measures, which are based on an extensive and systematic literature search, are described in Table SII (published online). The psychometric properties of an instrument are described according to the criteria of Terwee et al.36,69 Based on the accepted criteria, none of the instruments demonstrated satisfactory results for all properties (Table IV). The BOT-2 and the Beery VMI showed the most satisfactory results in terms of psychometric properties.
Table IV. Summary evaluation of psychometric quality of the instruments
Feasibility was evaluated according to the amount of administration time needed to complete the test, the equipment required, and the reliability of the recommended training time to administer the test. These items are summarized in Table II. The School-AMPS is the most time-consuming approach because it consists of an interview with the teacher, observation of two activities in the classroom, and interpretation of the scores. Training is required only for the School-AMPS.
This two-step systematic review of tests to assess handwriting readiness in 5- and 6-year-old kindergarten children identified 12 measures with the School-AMPS as the only occupation-based assessment. None of the tests reviewed fulfilled all of the criteria outlined against the TCOP, psychometric properties and feasibility.
The School-AMPS is the only test that assesses paper-and-pencil tasks at the level of occupation, activities, and performance components, according to the levels of the TCOP. The importance of children’s participation in life situations is gaining greater attention in the area of paediatric allied health care.70 Therefore, we searched the literature for an occupation-based assessment of pre-writing activities useful in the natural school setting where the environmental context can be evaluated.23 Unfortunately, the School-AMPS does not comply with all the levels of the TCOP. There is no opportunity in the School-AMPS to assess the qualitative ergonomic factors of paper-and-pencil tasks, such as information about a static or dynamic pencil grasp and information on an eventually forced arm/hand position, which are important factors to evaluate during this developmental period of pencil grip and wrist pattern.31 Furthermore, the School-AMPS does not evaluate visual motor integration, which is another important underlying component of writing readiness identified in the literature.6
From the three tests which evaluated paper-and-pencil tasks, copying ability, the domain of the SCRIPT, plays an influential role in the primary stages of learning letter formation.48 Copying letters is believed to represent the majority of handwriting activities performed by children in kindergarten,71 so this task should be included in an evaluation of writing readiness. Own name writing, an item in the WESS-P, is an important early measure of emergent writing skill.72 Children learn how to print letters from their experience of writing their own name.73 Consequently, own name writing should be a specific part of the assessment of writing readiness.
The DAP:QSS, a figure drawing assessment, is used as an indicator of cognitive level, socio-emotional development, and personality,74 as well as an indicator of intelligence.45 The test was not developed to be an indicator of early writing readiness; therefore, we do not recommend that the DAP:QSS should be part of a writing readiness assessment.
The two tests of fine motor coordination at the level of performance components that assess dexterity are the 9HPT and TIHM-R. Time as duration of a task is the most widely used index of dexterity and, therefore, the 9HPT is easy to use as a dexterity test.55 In-hand manipulation is considered to be an qualitative essential component of fine motor skills.30,75 A positive relation between in-hand manipulation and the performance of functional activities, such as handwriting and the use of scissors and cutlery, has been widely hypothesized.76 Case-Smith77,78 found that the time taken to rotate and translate pegs could be used to distinguish between children with and without fine motor delay. Because the TIHM-R evaluates fine motor coordination in a qualitative and quantitative way, this test should be part of the assessment of writing readiness.
The Beery VMI is a test often used internationally for the evaluation of visual motor integration. This test has been demonstrated to be particularly useful for the assessment of writing readiness in 5- and 6-year-old children.17 Therefore, this test should be part of the assessment of writing readiness.
General motor tests, such as the MPC, M-ABC-2, MMT, BOT-2, and Denver-II, evaluate fine and gross motor skills, including items of writing readiness. Only the M-ABC-2 and the BOT-2 have subtests with a total score on fine motor, an important performance component of writing readiness. The BOT-2 has eight items on fine motor skills whereas the M-ABC-2 has only three, suggesting that the fine motor score of the BOT-2 is more stable. This attribute has been confirmed by the authors of the M-ABC-2, who recommend caution in drawing conclusions based solely on manual dexterity items.60 The fine motor part of the BOT-2 and the M-ABC-2 should be a part of the assessment of writing readiness. The MPC, MMT and Denver II all have some items on fine motor and paper-and-pencil tasks. If these items are to be used as part of a writing readiness evaluation, research must be carried out to validate their effectiveness as part of such an assessment.
Based on content, the following seven tests should be useful in an assessment of writing readiness: the School-AMPS, SCRIPT, WESS-P, TIHM-R, Beery VMI, the M-ABC-2 and the fine motor part of the BOT-2.
Feasibility is one of the most significant variables influencing the actual use of an outcome measure in daily practice.79 A quick, inexpensive, and nonintrusive assessment can be implemented in daily practice without impediment and is feasible for therapists. However, the only occupation-based assessment in this review, the School-AMPS, does have a problem: to become a reliable and validated administrator of the School-AMPS, occupational therapy practitioners have to participate in a 1-week training course and become calibrated as a reliable rater. Rater calibration is a procedure that allows the AMPS Project International to determine each rater’s competency and whether or not they are scoring the School-AMPS in a valid and reliable manner. This is a time-consuming and financially burdensome criterion that may be a barrier for some practitioners in daily practice.
In terms of psychometric properties, none of the instruments demonstrate satisfactory results for all properties, according to the described criteria.36 From the seven tests that can be useful in an assessment of writing readiness, the BOT-2 and the Beery VMI show the most satisfactory results on psychometric properties. All seven instruments that can be used to assess aspects of writing readiness describe research on construct validity. Only the BOT-2 shows positive ratings on test–retest and interrater reliability, and the M-ABC-2 and the Beery VMI show doubtful scores on these aspects. Interrater and test–retest reliability are both very important aspects of the stability of a test and the basis for further psychometric research.80 However, until further reliability and validity studies are completed, therapists should be cautious in coming to clinical decisions related to writing readiness of children based solely on SCRIPT, WESS-P, and TIHM-R results.
There are several potential limitations to this review. Articles were included only if they were published in English, German, or Dutch. Therefore, some assessments may have been excluded. The first selection was made on abstracts; thus, it is theoretically possible that a handwriting readiness test could have been missed. However, we checked the reference lists from the included articles, so this is unlikely. The search revealed very well-known tests that have proven useful for assessing parts of the components of writing readiness. Finally, the rating for Table IV was performed only by the first author and, therefore, may be potentially biased.
The results of this systematic review identified only one occupation-based assessment that assesses different aspects of writing readiness suitable for kindergarten children aged 5 and 6 years, namely, the School-AMPS. However, the School-AMPS does not evaluate important aspects of the activity and performance component level, such as the ergonomic aspects of arm/hand position and pencil grip, and visual motor integration, and it requires training to administer. Therefore, an all-encompassing, feasible assessment instrument needs to be developed in order to enable testing of the writing readiness at all levels of the TCOP and to allow tailored advice and interventions. The results of this systematic review identify test items which may be useful in the development of a comprehensive evaluation tool of writing readiness in children.