Category of manuscript: Original article Title: Short-term Sensorimotor based intervention on handwriting performance in Elementary school children. Running title: Sensorimotor intervention on handwriting. Full names and academic degrees of the authors: Adel A Alhusaini1 PT, Ph.D., Ganeswara Rao Melam2*MPT Neurology, Syamala Buragadda3 MPT Neurology. 1 Assistant professor, 2,3, Researcher, Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Saudi Arabia *Corresponding author: Ganeswara Rao Melam, Researcher, Department of Rehabilitation Sciences, College of Applied Medical Sciences, and King Saud University, Riyadh, Saudi Arabia, Tel: +966 531262987; E-mail:
[email protected] Number of text pages: 8 Number of words: 4200 Reference pages: 3 Tables: 5 Figures: NIL Legends to figures. NIL
Short-term Sensorimotor based intervention on handwriting performance in Elementary school children Abstract Background: Children with handwriting problems can land up with problem lifelong, thereby affecting his academics and career ahead. Sensorimotor intervention therefore helps to alleviate the problem. Methods: Thirty-one (n=31) students (16 boys, 15 girls) were sorted using a Minnesota handwriting Assessment kit (MHA) which assesses legibility, form, alignment, size, and spacing (the primary variables in this subject) as well as rate. Finally, 10 students (7boys, 3 girls) aged 6-8 years [M=77.1±1.45] participated in an intervention program. Baseline measures of Minnesota handwriting Assessment (MHA), Handwriting Proficiency Screening Questionnaire (HPSQ), and grip strength of these students are taken. The same group of students acted as their own controls and were analyzed before the interventions and later after completion of the protocol.
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Results: There is a significant improvement in the MHA scores concerning legibility, form, alignment, size and spacing at the .05 level, with exception of rate. Paired t tests demonstrated significant changes at .05 level, in legibility, time performance and physical and emotional wellbeing domains of HPSQ and grip strength. Conclusion: The short- term sensorimotor-based intervention have shown significant improvement in hand writing performance of elementary school children. Key words Handwriting, elementary school, legibility, grip strength, performance.
Introduction: Handwriting is an academic skill that allows individuals to express their thoughts and feelings and communicate with others. The skill of handwriting is also referred to as a "graphomotor" skill, including visual-perceptual, orthographic coding, motor planning and execution, kinesthetic feedback and visual-motor coordination.1 Children spend 31 to 60% of their classroom time performing handwriting and other fine motor tasks, and difficulty in handwriting can influence a child’s academic achievement, which in turn affects the selfesteem.2, 3, 4 Although completing assignments by hand remains a prevalent practice in many elementary schools, an estimated 25–33% of students are struggling to achieve competency in this skill. 5, 6 12 - 30% of children fail in the motor learning of handwriting and therefore considered as poor writers or as having a dysgraphia7, namely a learning disability that concerns the mechanical handwriting skill, unrelated to reading or spelling abilities.8 Parents and teachers are not much aware of their child’s handwriting problem and the child can land up with problem lifelong, thereby affecting his academics and career ahead. Richards et al. who claim that it is rather a “brain-based skill that facilitates meaningmaking as writers externalize their cognitions through letter forms, the building blocks of written words and text” further support the concept that handwriting is not merely a mechanical or motor skill9. Similarly, Christensen suggests that handwriting is not only about training the hand (motor skill); but it is about how memory and orthographic processes must play together to be able to remember the letterforms and translate these figures onto the page automatically10. Research indicates that the traditional art of letter writing is going out as rising numbers of kids turn to email, text messages and social networking sites. It is frequently alleged that the pen is mightier than the sword, but the recent survey disclosed that less of the student population writes every day. Psychologists and neuroscientists say it is far too soon to declare handwriting a relic of the yesteryear. New evidence suggests that the links between handwriting and broader educational development run deep. 11, 12 Handwriting/fine-motor difficulties are well documented as serious impediments to academic learning for kindergarten and elementary school children. Research suggests that handwriting influences reading, writing 13, 14, 15, language and critical thinking16. Children with writing disorders had a leaning towards lower mathematics achievement, low verbal IQ, and increased attentional difficulties, and consistently assigned lower marks compared with
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controls2, 17, 18, 19. Handwriting difficulties in children include illegible handwriting and inefficient writing speed. Product legibility and performance time are important outcome parameters to assess and define poor handwriting.20, 21 In addition to legibility and timing deficits, observations by clinicians have revealed that children with dysgraphia complain more about fatigue and hand pain, and unwilling to write and do their homework are the signs representing a category of physical and emotional well-being.21, 22, 23, 24 Therefore, a child’s ability to write in a manner that is both legible and efficient, directly affects his or her school performance and academic advancement. Hence, it reinforces the importance of identifying handwriting difficulties as early as possible, both as a preventive and as a corrective aid. It is common for elementary-school children with handwriting difficulties including legibility problems to receive remedial education from their teacher or be referred to occupational therapy for evaluation and intervention25. The teacher is an important beginning of information about a child’s handwriting. Thus, teachers have been adopted as the main source of information to identify the non-proficient hand-writers. 26, 27, 28 Communication with teachers was a decisive element for carry-over of intervention strategies to facilitate student success.32 The common assumption among therapists is that a causal relationship exists between these lower-level processes and handwriting performance and that remediation of these skills will result in improved handwriting.29 Therefore, Occupational Therapists (OT’s) typically analyze handwriting difficulties into its sensorimotor and perceptual components to identify the foundational performance skills that seem to be associated with the functional skill of handwriting. Research has shown empirical evidence regarding the association of Performance skills with handwriting, but the contribution of these performance skills is not well understood. 29- 34 Sensori-motor approaches use some combination of sensory input and motor activities to ease the expected normal motor response and promote motor skill development35- 38. Research in the 20th century has led to several important advancements in the area of evaluation of handwriting difficulties, which are categorized as either global-holistic or as analytic evaluations.20, 39 Handwriting Proficiency Screening Questionnaire (HPSQ; Rosenblum, 2008), which was designed for use by teachers or therapists to pinpoint handwriting deficiency among school-age children.40, 41 The Minnesota Handwriting Test was developed to meet the need of occupational therapists for an educationally relevant, normreferenced test that can identify students with handwriting difficulties as well as document treatment effectiveness.42 Effectiveness of remedial handwriting intervention programs conducted by occupational therapists with positive outcomes were documented,29-36 but not much literature is available in Saudi Arabian context. The present study will help to identify the students in school who have poor handwriting and therefore help to improve their overall academic activities. The purpose of this study was to evaluate the additive effects of sensorimotor intervention on the child's handwriting. Research questions involved the possible effects of the intervention on specific qualities of handwriting (legibility, form, alignment, size, and spacing) and on speed. Secondary research questions involved possible effects of training in teacher assessment done by HPSQ and grip strength.
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Methods Research design This prospective, one-group, pretest–posttest experimental design was used to evaluate the effectiveness of a sensorimotor intervention. We used a convenience sample of public school classrooms of International, British School, Riyadh, Saudi Arabia. The Research ethics committee of College of Applied Medical Sciences, King Saud University [CAMS 3534/35-Ethics Number] and the School Authorities approved the study. Measures of handwriting were administered at pretest and posttest. Sample The students of two first grade classrooms for whom English was their first language, but no identified educational need was selected to participate in the study. The parents were informed about the study during student orientation and completed consent forms at the time of the teachers’ initial assessment. Thirty-one (N=31) students (16 boys, 15 girls) were screened using a Minnesota handwriting Assessment kit (MHA) which assesses legibility, form, alignment, size, and spacing(the main variables in this study) as well as rate. Twenty students fulfilled the inclusion criteria of performing somewhat below peers or performing well below peers in at least two components of MHA. Among them, thirteen students agreed to participate in the intervention program, later two students left the school, and one student left the study before the actual intervention. Finally, 10 students (7boys, 3 girls) aged 6-8 years [M=77.1, SD=1.45] participated in intervention program [Table 1]. The research plan called for exclusion from the study for any student of direct intervention for handwriting problems prior to the study and missing the intervention more than 2 sessions. Schoolteacher administered Handwriting Proficiency Screening Questionnaire (HPSQ) prior to administration of the protocol. Handgrip strength was taken by using a Jamar hand held Dynamometry. Instrument: The Minnesota handwriting Assessment (MHT) was used in the current study as a screening tool and to measure outcome38, 42. The near-point copy assessment assesses for Rate, Legibility, Form, Alignment, Size, and Spacing. Performance is then judged and classified as, “Performing like Peers” (upper 75th percentile), “Performing below Peers” (bottom 5-25th percentile), and “Performing Well-Below their Peers” (bottom 5th percentile). Test sheets for the MHT are available in both standard manuscript and D’Nealian script style to fit the instructional style of each classroom. Students copy words from a pre-printed example onto marked lines below the example. The words in the example (“the quick brown fox jumped over the lazy dogs”) include all letters of the alphabet. The handwriting sample was scored based on specific directions for each category (legibility, form, alignment, size, and spacing) and rate. Each category was scored based on the error rate with a maximum potential score of 34. Rate or speed was scored by counting the number of letters completed in 2.5 minutes.38, 42 Handwriting Proficiency Screening Questionnaire (HPSQ): Identification of handwriting deficiency among school-aged children and is appropriate for varied academic and clinical purposes. The tool demonstrated good internal consistency (α =. 90). Test–retest reliability of
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the score revealed an intraclass correlation coefficient (ICC) of 0. 84 and interrater reliability of ICC 0. 92.40, 41 Non-Proficient Hand writers: Students having a score of 14 and above on the HPSQ and Proficient Hand writers: Students having a score of less than 14 on the HPSQ. Jamar Hand held Dynamometer: Isometric grip strength for both the dominant and nondominant hand was seen utilizing a calibrated hydraulic handheld dynamometer (HHD), the Jamar dynamometer (Jamar, Bolingbrook, IL, USA). 43, 44 Procedure: This survey was conducted during the time of March 2014- March 2015. The children (N=31) [16 boys, 15 girls] of two first grade classrooms were administered Minnesota handwriting Assessment kit. Students are seated in appropriate height for their size with a distraction free environment. Stimulus sheet for both manuscript and D’Nelian style handwriting were administered after explaining the directions of writing process as per guidelines of the kit. After evaluating the scores of MMT, the students who fulfilled the inclusion criteria were chosen to take part in the study (N=20). The school authorities regarding the voluntary participation of students in sensory intervention program to improve their handwriting skills informed parents. Ultimately, 10 students (7 boys, 3 girls) agreed to participate in the study. These students were promoted to 2nd grade at the start of the intervention. Baseline measures of HPSQ, MMT and grip strength of these students are taken. The same group of students played as their own controls and were broken down before the interventions and later after completion of the protocol. The sensorimotor-based intervention group took in 2 times per week (Monday and Wednesday) from 11:45am-12:35pm for 5 weeks during regularly scheduled school hours. These students are given training in separate classrooms. Each 40-minute session with 10 minutes of gross and fine motor warm up activities45 and followed by 30 minutes of sensorimotor component activities in visual perception, visual-motor integration, proprioception/ kinesthesia, and in-hand manipulation. 29 The intervention was provided in two small groups in quiet, private rooms at the schools. One occupational therapist and a physical therapist with paediatric experience along with special education teacher were present during the intervention. Treating therapists were supplied with a toolbox of games, activities work sheets, equipment, treatment ideas for each factor, as easily as the schedule for rotation of activities29. All the students participated in the initial warm up session and requested to do all sensorimotor activities in random order. However, the treating therapists and students were permitted flexibility to choose the activities during each session from the list supplied and to vary the format, order, and the materials used in the interventions. Therapists and teachers assigned to the stations monitor students and provide specific feedback, support and instruction as needed. The students rotated the stations in random order to perform the list of activities [appendix-1] and therapists emphasized on performing all activities. Statistical analysis: The data were analyzed using the SPSS 22 software package and a 95% confidence interval. Descriptive statistics were used for subject’s demographic characteristics. The level of significance used was 0.05. Repeated measures ANOVA were used for within group comparisons. The independent T test is applied to analyze pairwise comparison This article is protected by copyright. All rights reserved.
Results: Thirty-one children have participated in this study, and 10 students (7 male and 3 female) who met the inclusion criteria completed whole study. The subjects did as their controls at baseline followed without intervention for 6 months and later reassessed before and after a short-term sensorimotor intervention for a period of 5 weeks. The features of the sample are reported in table 1.
Discussion: This study addressed the need for further research on handwriting remediation and we investigated the effectiveness of short-term sensorimotor intervention (SM) on handwriting performance in elementary school children. Our first hypothesis suggested that children receiving intervention would show substantial improvement in handwriting performance. The results of the study showed that short-term training had beneficial effects on MHA scores of rate, legibility, form, alignment, size and spacing in both the manuscript and D’Nealian scripts. The teacher perception of student handwriting assessed by Handwriting proficiency screening questionnaire (HPSQ) showed a significant difference in all the domains, i.e., Legibility, performance time, physical and emotional components after the intervention. Handgrip strength improved after the intervention was recorded by Jamar hand held dynamometry. The students were followed longitudinally from the grade I without any intervention until grade II, thereafter the short-term SM intervention program for a period of 5 weeks with twice the sessions were done. The short bout of intervention showed a spectacular improvement in handwriting scores of MMT, except the rate in manuscript style but showed improvement in D’Nealian script. The rate scores were not significantly improved which was supported by other studies, as the rate was not associated with the function. Studies examining the correlation between handwriting speed and legibility have yielded contradictory findings. 38 As the students instructed to write as neatly as possible the speed of handwriting was decreased despite the intervention. The improvement in rate scores of D’Nealian script may be attributed to the curriculum of the school. The other variables of MMT, such legibility, form, alignment, size and spacing reached the statistical significance at the 0.05 level. The strong individual scores for improvement in these variables will be attributed to the sensorimotor intervention. The program has components similar to the handwriting and writing interventions developed by Denton PL et.al emphasizing critical elements of sensorimotor intervention. 29, 33 Ninety percent of Canadian OTs & Ninety-two percent of American school-based OTs surveyed used sensorimotor approaches to remediate handwriting31, 34. Earlier studies have been conducted to explore potential factors that may contribute to handwriting difficulties. The intrinsic factors include: kinesthesia, fine motor skills, eye-hand coordination, visual perceptual skills, and visual motor integration and extrinsic factors include writing posture, chair, desk height was believed to have a relationship of handwriting. 2 In this study, therefore emphasis is given to both intrinsic and extrinsic factors to improve the skills of handwriting. In the sensorimotor approach, interventions oriented to the child’s sensory systems, and by providing a variety of sensory experiences with appropriate feedback to improve the motor performance. Apart from the sensorimotor approaches, the additional findings observed such This article is protected by copyright. All rights reserved.
paper position, writing surfaces, grip strength, and posture were considered. Therapists acted in close collaboration with teachers in regard to eliminate these extrinsic factors and thereafter focus on motor planning abilities. Our findings indicate that Case-Smith J et.al, developed integrated handwriting program, which showed large, significant gains in handwriting legibility and speed and the results maintained at 6-month follow-up 32, 35 . Mackay N et.al, found that the Log Handwriting Program improved children's writing legibility. Legibility improved by a mean of 4.1 points (95% confidence interval = 2.5 to 5.7); form, 5.3 points; alignment, 7.8 points; size, 7.9 points; and space, 5.3 points. Speed decreased by 3.9 points34. The findings of this study agree with the above studies, emphasizing the importance of SM based intervention taking into account the extrinsic factors. Other sensory-motor based programs have resulted in little or no effect on handwriting performance when compared with traditional handwriting instruction 29, 30, 38. Limitations: Pupils in this study were chosen by convenience sample from one International British school in Riyadh. The initial plan was to recruit students for control and experimental group. This could not be investigated due to low recruitment numbers. The sample size was small and limited to parents who agreed to have their child involved in the study. Whether a single intervention or a combination of intervention strategies was the cause of improvement was not known. This could have biased the sample, as there is no actual control group in the study. Students in this study were homogeneous having a similar preschool experience.
Future Research The authors recommend that the subjective and objective standards of handwriting analysis must be implemented in schools to analyze the handwriting difficulties. Thus, it will serve to use sensitive and evidence based strategies rather than intuition based on righting the problems in hand. While teachers are skilled at informally identifying poor handwriting, the MHT and HPSQ tools help to support the teacher’s subjective judgement of poor quality of writing. This evidence based approaches help to document the problem and plan adequate measures to counter the problem in the early phases. The research discussed above suggests that role of handwriting efficiency in the writing of young children has been underestimated in mainstream education and appropriate sensorymotor interventions are helpful. Sensorimotor intervention is an evidence-based protocol that can be recommended by practitioners for effective printing instruction in the classroom or institutional level. Acknowledgments The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding this work through research group no RGP-VPP-256. We are indebted to the children and their parents of British International School, Riyadh, for enthusiastic participation, and extend special thanks to school teachers involved in the present study. We also thank Mr Emad Takrouni for assistance in collecting the data. The authors declare no conflicts of interest. This article is protected by copyright. All rights reserved.
Author contributions AA, and GM designed the study; GM and SB collected data; AA and SB analyzed the data; AA, GM, and SB wrote the manuscript. All authors read and approved the final manuscript.
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Table: 1 Sample description Characteristic
Group
Mean age (years) (N=10)
77.1±1.45
Hand dominance
Right-8 Left- 2
Gender
Male-7 Female -3
Ethnicity
Arabic 8 British- 2
Table: 2 Within-Subjects Factors (Manuscript)-MHA Manuscript (n=10) Rate
Time
Baseline Pre-intervention Post-intervention Legibility Baseline Pre-intervention Post-intervention Form Baseline Pre-intervention Post-intervention Alignment Baseline Pre-intervention Post-intervention Size Baseline Pre-intervention Post-intervention Spacing Baseline Pre-intervention Post-intervention *-significant **_non-significant
M± SD
F
(p≤0. 05)
20 ±7.77 21.3±3.31 27.4±7.94 21±8.52 26.5±7.42 33.7±0.68 17.50±5.29 20.80±5.54 30.80±2.15 5.80±6.85 18.00±4.85 30.90±4.31 8.20±8.35 20.20±4.49 32.20±2.74 20.50±8.18 23.00±5.85 30.90±3.57
3.886
.080**
22.965
.001*
61.682
.000*
72.610
.000*
66.122
.000*
13.183
.005*
Repeated measures ANOVA on legibility, form, alignment, size and spacing reached statistical significance at the .05 level*, with exception of rate**.
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Table: 3 Within-Subjects Factors (D’Nealian)-MHA Manuscript (n=10) Rate
Time
M± SD
F
(p≤0. 05)
Baseline 20.60±6.68 31.954 .000* Pre-intervention 25.0±7.71 Post-intervention 33.6±1.27 Legibility Baseline 26.7±5.58 15.281 .004* Pre-intervention 27.0±6.18 Post-intervention 33.8±0.42 Form Baseline 22.00±5.01 25.175 .001* Pre-intervention 23.20±4.98 Post-intervention 30.60±1.65 Alignment Baseline 8.60±7.98 58.827 .000* Pre-intervention 20.00±8.69 Post-intervention 29.80±4.94 Size Baseline 11.30±8.76 57.168 .000* Pre-intervention 22.20±9.17 Post-intervention 32.40±1.51 Spacing Baseline 25.50±6.67 8.288 .018* Pre-intervention 25.70±5.36 Post-intervention 31.00±1.76 Repeated measures ANOVA on rate, legibility, form, alignment, size and spacing reached statistical significance at the.05 levels. *-Significant, **-Non significant
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Table: 4 Post intervention changes in MHA for Manuscript & D’Nealian style Manuscript (n=10)
t
(p≤0. 05)
Rate
-2.141
.061**
Legibility
-2.951
.016*
Form
-5.752
.000*
Alignment
-8.310
.000*
Size
-10.757
.000*
Spacing
-4.570
.001*
Rate
-3.459
.007**
Legibility
-3.374
.008*
Form
-3.805
.004*
Alignment
-4.889
.001*
Size
-10.757
.000*
Spacing
-2.994
.015*
D’Nealian (n=10)
Test = Paired Sample test, *-significant, **-non-significant Paired t tests demonstrated significant changes at.05 levels in manuscript and D’Nealian script, in all the variables of MMT except the rate** during the intervention phase.
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Table: 5 Paired Samples Test (HPSQ) and Grip strength Pre
Post
(p≤0. 05)
Legibility domain
5.80±3.58
2.90±2.52
.020*
Time performance
6.00±3.24
4.00±2.49
.019*
Physical & emotion wellbeing
8.50±6.02
3.10±2.81
.012*
Total
19.90±9.66
10.00±6.47
.002*
DOM_GRIP
17.50±5.89
20.50±5.51
.024*
NDOM_GRIP
14.00±6.99
18.00±4.22
.022*
Characteristics HPSQ
Grip strength
DOM-Dominant, NDOM-Non dominant. *-significant, **-Non significant Paired t tests demonstrated significant changes at .05 level, in legibility, time performance and physical and emotional wellbeing domains of HPSQ. Grip strength measures of dominant and non-dominant limb showed significant difference after the intervention at the significance level of 0.05.
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