The Influence of
H
Ergonomic Factors and
Perceptual-Motor
Abilities on Handwriting
Performance
Mei Hui Tseng, Sharon A. Cermak
Key Words: child. gross and fine motor
evaluation
DlfficullY with handwriting is one of the mosl frequent
reasons that children in the public schools are re-
ferred to occupational Iherapy Current research on
the injluence of er;gonomic faclors, such as pencil grip
and pressure, and perceptual-motor factors tradition-
al~v believed to affect handwriting, is reviewed Fac-
tors such as visual perception show little relationship
to handwriting, whereas tactiLe-kinestbetic, visual-
motor, and motor planning appear to be more cLoselv
related to handwriting By better understanding the
ergonomic and'perceptuctL-motor factors that contrib-
ute to and injluence handwriting, therapists will be
better able to design rationallv based intervention
programs,
Mei lfui Tseng, SeO, aiR is a Lecturer, OCcu[Btional Therapv
Division, School of Rehabilita[ion Medicine, National Taiwan
University, Taipei, Taiwan. At the time of this s[lId\', she was a
doctoral student in the Doctoral Program in Therapeutic
Studies, Department of Occupational Therapy, Boston Univer-
sit\', Sargent College, Boston, Massachusetts.
Sharon A. Cecmak, FliD. OTR, FAUTA. is Associate hofessor of Oc-
cupational Therary and Co·Director, Neurobehavioral Reha-
bilitation Research Center, Boston University, Sargem College,
635 Commonwealth Avenue, Boston, i\'!assachuse[ts 02215.
This articte was accepted /01' puhlica/ion June l. 1993
Jhe American joumat of Occupationat Therapy
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andwriting is an important skill for school-aged
children. A student's ability to produce fluent
and legible writing is important for expreSSing,
communicating, and recording ideas as well as for educa-
tional development (Phelps, Stempel, & Speck, 1985),
Handwriting problems interfere with the child's ability to
show what he or she knows. The child with handwriting
problems often cannot finish assignments on time; be-
cause writing is difficult, the child may tlY to complete a
written assignment in as few words as possible. When a
child has to focus on the mechanical aspects of writing, he
or she cannot fully attend to the content of information,
Thus, there is a tradeoff between concentration on learn-
ing and concentration on writing (Levine, 1985, 1987;
McHale & Cermak, 1992).
Problems in handwriting are frequent reasons why
children in the public schools are referred to occupation-
al therapv (Cermak, 1991; Reisman, 1991; Schneck &
Henderson, 1990). This paper reviews current research
regarding ergonomic and perceptual-motor contribu·
tions to handwriting and discusses implications for reme-
diation It is proposed that understanding the mecha-
nisms and factors that underlie and contribute to
handwriting performance will help therapists to design
more effective treatment programs.
Ergonomic Factors
Ergonomics, the study of work, involves the interaction
and the fit between human capabilities and the demands
of a job (Smith, 1989). In this paper, the job is handwrit-
ing, Two factors, pencil grip and pressure on the writing
instrument or surface, are examined,
Pencil Gnp
Pencil grip is an aspect of handwriting that has been
addressed by occupational therapists who work with chil-
dren with 'writing problems (Schneck & Henderson,
1990). Although the dynamic tripod grip is generally en-
couraged by educators and therapists, numerous vari-
ations of grip exist. These variations have often been seen
in children with disabilities who have poor handwriting,
However, it is not clear to what extent an atypical grip
contributes to poor handwriting (Schneck, 1991; Ziviani,
1987).
Most children between the ages of 4 and 6 years
develop dynamic tripod grips (Rosenhloom & Horton,
1971; Schneck, 1990; Schneck & Henderson, 1990). As
children grow older, they seem to refine the dynamic
tripod grip. Ziviani's (1983) resulrs place that develop-
ment between the ages of 7 and 14 years. She used four
components to measure gt'ip degree of index finger flex-
ion, degree offorearm pmnation and supination, number
of fingers used on the pencil shaft, and thumh and forefin-
ger opposition, However, she observed developmental
919
 trends fOt" the first two components onl\'. Furthermore,
much diversity in grips was noted even among the popu-
lation without handicap. Variation was related [0 the
aforementioned four aspects of the grip. These four as-
pects were further examined by Ziviani and Elkins (1986)
for their effect on speed and legibility of writing. Results
showed that speed and legibility were not affected even
by the most atypical grir patterns. The authors concluded
that grip does nor necessarily adversely affect handwrit-
ing performance. This finding gains suPPOrt from a later
study by Ziviani, Hayes, and Chant (1990) and a study by
Sassoon, Nimmo-Smith, and Wing (1986). Sassoon et al.
(1986) surveyed pencil grip in children between the ages
of 7 and 16 years, and investigated the relationship be-
tween pencil grip and writing speed. Their analysis of
penhold was based initially on jacobsen and Sperling's
(1976) previous classification of hand grip, in which the
subjects were asked to hold a variety of objects. Children
were grouped according to their grip; writing speeds
were recorded. Results showed that the speed was not
affected by an unconventional grip. In contrast, Schneck
(1991) compared pencil-grip pattern in first graders and
found that poor writers had lower grip scores than good
writers. Further analysis revealed that poor writers with
decreased kinesthetic feedback were the group with low
grip scores (Schneck, 1991).
In summary, it has long been assumed that an awk-
ward or unconventional grip would affect the speed and
legibility of a child's handwriting. However, thiS assump-
tion does not seem to be supported by research findings
with the excertion of Schneck's (1991) study, which was
based on a younger sample. According to the current
research, Ziviani (1987) concluded that poor writers are
more likely to demonstrate a great variation of atypical
grips, which are not, on their own, predictors of poor
handwriting. She further suggested that because hand-
writing is a motor skill, different variations are exrected
and are nor necessarily harmful to handwriting perform-
ance. However, some grips may make handwriting easier
than others. The presence of writer's cramp may indicate
that a grip is dysfunctional and is putting stress on certain
muscle groups (Ziviani, 1987). Further study is needed to
help identify the precise nature of such dysfunctional
grips. It should be emphasized that, to date, research
examining the relationship between grip and handwriting
has only looked at short samples of writing It is possible
that poor grip may result in quicker fatigue such that it
would be reflected in a decrease in speed or accuracy
when a large quantity of handwriting is demanded. More-
over, as research on pencil grip with children only ana-
lyzed the grir itself. Future research may need to focus on
the dynamic characteristics of use of the pencil.
Pressure on Writing Instrument and SUI/ace
Handwriting requires well-integrated movements of dif-
920
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ferent body parts. The delicate movements of the fingers
must be coordinated with fixation and release at the wrist
and elbow. At the same time, the shoulder and trunk
must be stabilized (Ziviani, 1987) .It is thought that a child
with low muscle tone uses more effort to hold nor only
the head and body up against the pull of gravity, but also a
writing implement. Clinicians have observed that, for chil-
dren with low muscle tone, the pressure of lines in their
writing is often light and their handwriting deteriorates
over time. Moreover, these children tend to rest their
heads on their hands or arms while sitting at a desk,
which may affect their perception of what they have writ-
ten and result in failure to correct (Gajraj, 1982).
Currently, much of the discussion of the effect of low
muscle tone on legibility of handwriting comes from clini-
cal observations. Research with children that specifically
addresses the extent to which low muscle tone affects
legibility of handwriting has not been reported.
In addition to the influence of low muscle tone on
handwriting, it seems logical that handwriting would suf-
fer From muscle stress and tension that impede the free-
flOWing movements necessary for legibility. Evidence sug-
gests that tension is an important factor affecting
handwriting performance. Herrick and Otto (1961) have
pointed out that there are actually three measures of
pressure: those of the fingers on the barrel of the pen, of
the pen on the writing surface, and of the hand resting on
the writing surface. Harris and Rarick (1957, 1959; Rarick
& Harris, 1963) have studied the point pressure on the
writing surface as it relates to speed and legibility in hand-
writing. Their findings revealed that force variation had a
closer relationship with legibility and speed in handwrit-
ing than had absolute point pressure (Harris & Rarick,
1957, 1959). Their conclusion was that increased speed
leads to increased variation in force application such that
motor coordination is disrupted and handwriting legibil-
ity is negatively affected. On the basis of Harris and Rar-
ick's studies, it appears that handwriting teaching should
be individualized in terms of each student's particular
motor control ability so that handwriting speed andleveJ
of pressure can be optimally developed at the student'S
pace.
The influence of relaxation training on handwriting
performance has been studied in various groups. Caner
and Synolds (1974) found that relaxation training im-
proved handwriting quality in boys with minimal brain
injuries, and the improvement transferred to nonexperi-
mental situations. However, no control group was includ-
ed for comparison. jackson and Hughes (1978) support-
ed Caner and Synolds' findings by using a relaxation
training program on a group of typical fourth graders
rated as poor handwriters. Hughes, jackson, DuBois, and
Erwin (1979) had similar findings. They concluded that
relaxation training, when carried out in a group, may be
more effective for improving handwriting skills than a
biofeedback training program given individually. Similar
October 1993, Volume 47, Nztmbel' 10
 results were obtained by Jackson, Jolly, and Hamilton
(1980) who found that relaxation training combined with
handwriting suggestions and traditional handwriting
teaching was the most effective method for improving
poor handwriting,
In summary, the research findings seem to imply
that relaxation training, when administered by itself or as
part of a larger program, can lead to improved handwrit-
ing performance by reducing muscle tension, Neverthe-
less, because the relaxation training used by Carter and
Synolds (1974) and Jackson and Hughes (1978) incorpo-
rated not only relaxation but also handwriting sugges-
tions, it is not clear whether the improvement resulted
from relaxation, the handwriting suggestions, or both,
Thus, further research is needed to examine the exact
effect of rel<L'(ation training on the reduction of muscle
tension and the relationshir between muscle tension,
muscle tone, and handwriting performance.
implications for Practice
"Both occupational therapy and ergonomics are con-
cerned with the individual's adaptation to and interaction
with the physical environment" (Smith, 1989, p. 128). In
ergonomics, the goal is to accommodate the design of the
workplace and the job to the worker's capabilities (Smith,
1989). In this sense, a variety of adaptations can be con-
sidered to help the child with handwriting within the
schoo.l environment. These may include adaptations to
the environment (school setting) such as a change in
desk or seat size, use of vertical writing surfaces, use of a
ta pe recorder to reduce the demands of writing, or use of
a word processor to alter the perceptual-motor demands
of graphomotor production. Intervention may also in-
volve use of different or adapted tools such as an adapted
pencil grip, markers instead of pencils, wiele instead of
narrow ruled paper, or graph paper. Ergonomic litera-
ture, IXimarily with adults, has shown that factors such as
the Jength, diameter, and shape of hand tools determine
their optimal efficiencv (Bruening & Beaulieu, 1990:
Johnson, 1991). Benbow (in press) has fuUy discussed a
variety of adaptations to enable a better match between
the child's abilities and the task of handwriting. Finallv,
changes may be maele in job design, such as having the
child write two short papers rather than one long paper.
The Role of Perceptual-Motor Abilities in
Handwriting Performance
The reasons that some children find it difficult to produce
clear, legible handwriting are many and complex, Im-
paired kinesthetic feedback, poor visual perception, and
problems in visual-moror integration, fine motor skills,
and moror planning are factors often cited in the litera-
ture to account for handwriting difficulties (AJston & Tay-
Tbe American Jownat of Occupational Therapv
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lor, 1987; Gaddes, 1985; Levine, 1987; Lindsey &. Beck,
1984). The role of each factor is reviewed and discussed
The Role of Kin estbetic Perception
Kinesthetic perception is the sense of position and move-
ment of limbs and body. Through kinesthesia, without
vision, we perceive the position of our limbs relative to
our body (Sage, 1984). Describing the role of kinesthesia
in the acquisition and performance of h,lIldwriting,
laszlo, BairslOw, and colleagues suggested that kinesthe-
sia plays two roles in handwriting performance: It pro-
vides ongOing error information and references for subse-
quent repetitions of the motor act. They further stated
that a child who has difficulty perceiving or storing kin-
esthetic information will have difficulty not only with
handwriting but also with imprOving performance
through practice (Laszlo & l3airstow, 1984; Laszlo, Bair-
stow, & Bartrip, 1988; Laszlo, BairslOw, Banrip, & Rolfe,
1988).
Levine (1987) addressed the adverse effect of im-
paired kinesthetic feedback on the pencil gl'ip, In his
discussion of low productivity in school-aged children,
Levine suggested that three motoric priorities must be
balanced in the process of handwriting: stable pencil grip,
maximum maneuverability of the writing implement, and
movement of the writing implement so that transmission
of kinesthetic feedback is possible. Levine stated thar
these three priorities may interact negatively with each
other to some extent. That is, mobility may be limited by
increased stability, but an excess of mobility ma)' interfere
with some of the fine-tuned feedback.
According to Levine (1987), children may compen-
sate for impaired kinesthetic feedback bv developing an
:lwkward, inefficient pencil grip. They establish a reper-
tOire of contorted grips that exert excessive pressure on
the pencil, which selves to provide increased kinesthetic
feedback. The resuJt of this compensation is an inability
to attain the dvnamic tripod grip, and, because of the
need to constantlv visually monitor their work, their writ-
ing becomes labOl'ious rather than automatic. The lack of
speed causes a proportional loss in the quantity of writing
thev are capable of. Levine, Oberklaid, and Meltzer (1981)
noted that 20 of26 children (77%) who were identified as
haVing developmental output failure had awkvvard pencil
grips. Schneck (1991) also supported the importance of
kinesthesia in some aspects of handwriting. In her study,
children with low grip scores and poor handwriting were
the children wi th decreased kinesthetic feedback.
Ziviani et a!. (1990) studied handwriting problems in
a group of children with spina bifida and found that kines-
thesia (as measUl'ed by the Kinesthesia Test of the South-
ern California Sensory Integration Tests [Ayres, 1972,
19801), receptive language, age, and handedness ac-
counted for 55% of the variability of the alignment of
words, and that kinesthesia along with age accounted for
71 % of the variability of letter formation.
921
 Laszlo and Bairstow (1983) investigated the relation- Table 1
ship between kinesthesia, as measured by the Kinesthetic Results of T-test on Pretraining Scores Versus
Postraining Scores in Kinesthesia and Drawing
Sensitivity Test, and skilled motor behavior Two groups
of children with low kinesthetic scores, as determined by Group 1 Group 2 Group 3

the Kinesthetic Sensitivity Test, and a kinesthetically able
control group, were pretested on kinesthetic acuity, kin-
esthetic memory, and certain drawing tasks. One group
with kinesthetic impairment was trained over 6 days on
kinesthetic acuity and memory tasks and on the drawing
of a square, a diamond, and a triangle under a masking
box. The second group with kinesthetic impairment was
trained only on the drawing tasks over the 6 days. The
control group also was trained on the drawing tasks A
comparison of pretest scores and scores on posttests
indicated significant improvement on all three tests by
the group receiving kinesthetic training, but not by the
other two groups, with the exception that the control
group had significant improvement on the kinesthetic
memory tests.
During the second stage of the study, the second
experimental group received training on the tests of kin-
esthetic ability, but was trained no further in drawing.
Once this second training phase was completed, they
were again given the tasks of copying a square, a dia-
mond, and a triangle under the masking box. After kin-
esthetic training, their resulting drawing scores were sig-
nificantly higher than the scores in the prior phase, which
did not include kinesthetic training. The authors conclud-
ed that
These results confirm the notion that kinesthesis is necessary for
thc efficient performance and acquisition of skilled movements.
In group 1, childt'en trained on both drawing and kinesthetic tasks
improved in drawing, while drawing training alone in group 2 did
not lead to any improvement in the drawing skill of subjects in
group 2. (1983, p. 419)
Although a control group was employed, no com-
parison was made between experimental and control
groups. Instead, the investigators compared pretraining
and posttraining scores for each group. On the basis of
this type of comparison, extraneous variables such as
maturation cannot be ruled out as competing explana-
tions; thus, the improvement cannot be attributed solely
to kinesthetic training. Moreover, the kinesthetic and
draWing training resemble the tasks for posttest. The ef-
fect of practice may account for the improvement. None-
theless, the d-indexes for Group 1 are substantially great-
er for kinesthetic memory and drawing tests than those
for the other groups (see Table 1). Therefore, it appears
that kinesthetic training affects kinesthetic memory and
drawing performance. Taken together, the findings of
Ziviani et aL (1990) and Laszlo and BairstOw (1983) ap-
pear to support the latter's theoretical conception that
kinesthetic input is important in the process of skiJled
movement such as handwriting (Laszlo & BairstOw, 1984;
Laszlo, Bairstow, & Bartrip, 1988; laszlo, l3airstow, Bar-
trip, & Rolfe, 1988).
Tests p< d p< d p< d
Kinesthetic
acuity 219 05 165 161 ns 122 107 ns 081
Kinesthctic
memory 3.4901 263 08 ns 0.6 2.4 .05 181
Drawing 35501 2.68 102 ns 0.77 1.94 ns 1.46
No/e. d-index is effect size and was calculated by Tseng based on data
from Laszlo, l I, & Bairstow, P l (1983) Kinesthesis: Its measuremcnt
training and relationship to motor control QuarterlyJournal ofE::-peri·
mental Psychologl', 35a, 411-42 I.
ns = not significant
df=7
The Role of Visual Perceplion
Although much writing has explored the relationship be-
tween visual perception and reading disabilities, the lit-
erature on the relationship between visual perception
and handwriting is limited. According to Ayres (1958),
handwriting is a visual-motor performance task of the
upper extremities Ayres did not directly postulate the
process for learning handwriting skill, although she drew
upon the work of Strauss and Kephart (1955) and ad-
dressed the importance of visual perception in the motor
act. Strauss and Kephart (1955) considered it crucial to
proVide, through visual perception, a substantial ancl
clearly structured pattern for the motor action to follow.
In that way, better coordination could be achieved by the
provision of better Visual-perceptual stimulation. Fur-
thermore, Strauss and Kephan believed that visual per·
ception was used to give meaning to a pattern generated
by proprioceptive perception.
In contrast, Laszlo and Bairstow (1984) assumed that
by the time the child can write, he or she has a fully
developed sense of visual shape discrimination. They ar-
gued that kinesthetic perception, rather than visual per-
ception, contributes to ongoing error detection and cor-
rection programming. This argument stems from the fact
that there is a temporal delay between programming the
movement to write the letter and actually seeing it on the
page.
Despite the limited amount of literature on the rela-
tionship between visual perception and handwriting, vi-
sual perception is the perceptual-motor skill examined
most frequently in relation to handwriting. However, re-
sults have not proVided convincing evidence for the con-
tention that visual perception plays an important role in
handwriting performance. Four studies have used a cor-
relational design to investiga[e the role of visual percep-
tion in handwriting. Lewis ancl Lewis (1965) investigated
the relationship between [he types of handwriting errors
and visual perception, as measured by the matching sub-
[est of the Metropolitan Reading Readiness Test, in 354
non repeating first graders. Only a slight rc1acionship be-
tween visual perception ancl the incidence of errors in

922 October 1993. Volume 47, Number 10

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 letter formation was demonstrated. The authors did not
report how the data were analyzed or how the exact
correlation was established.
Chapman and Wedell (1972) examined the relation-
ship between reversal errors in children's handwriting
and perceptual-motor abilities in a group of children
aged 7.5 to 85 years. The Perceptual Quotients of the
Frostig Developmental Test of Visual Perception (DTVP)
(FroStig, 1964) - a test designed to measure the specific
visual percC[)[ual skills of eye-hand coordination, figure-
ground perception, form constancy, position in space,
and spatial relations - were significantly lower in the
group of children with reversal errors. Among the sub-
tests, only the Position in Space scores demonstrated
statistically significJm differences between children with
and without reversal errors However, the reliability of
the individual subtests on the Frostig is inadequate for
in terpreta tion
Yost and Lesiak (1980) examined the relationship
between handwriting ability and pel-formancc on the
DTVP in a group of 60 nonrepeating first graders. No
significant relationship was found between good or poor
handwriting ability and a Perceptual Quotient score
(comparable [0 an IQ score) of above or below 90 on the
DTVP. The validity of the swdy by Yost and Lesiak (1980)
can be questioned because the DTVP has a strong mowr
componenr. Ziviani et al. (1990), in their srud)' of h:llld-
writing problems in a group of 34 children with spina
bificla, chose the Test of Visual Perceprual Skills (Non-
motor) (Gardner, 1982) because it required minimal mo-
tal- responses. However, the role of visual perception in
handwriting performance was not subst~lntiated in their
srudy.
Of the four swdies with a correlation design, those
of Yost and Lesiak (1980) and /',iviani et aL (1990) did not
find significant correlations between visual perception
and handwriting ability, whereas Lewis and Lewis (1965)
and Chapman ond Wedell (1972) found a slight relation-
ship. Each stucly ha::. its own limit<1tions. No statistics vvere
I'cportecl on the result of the relationship between elTor
types and visual perception in the Le\\i~ and Lewis stuck
(1965). The stuely of Chapman and Wedell (1972) ael-
dressed only a specific a.speer of handwriting perform-
ance, that is, reversal enors. The results of Yost and Le-
siak (1980) were confounded by lT1utm responses
involved in the UIVP The study by Ziviani et al (1990)
was on a specific population with spina bifida, a s~lmple
with known mowr deficits that can affect handwriting.
Their results cannot be generalized to othcr populations;
thus, funheL n:scarlh is warranted to provide cumulative
data for exal11 II ling the jJroposed role of visual perception
in handwriting.
The Role of Visua!~l'v!otorintegratioll
Visual-motor integration i~ conceptuali7.ed as the abilit)T
The American Journat o/Occupatiollal TherapJ'
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to integrate the visual image of letters or shapes with the
appropriate motor response (Beery & Buktenica, 1967;
Sovik, 1975). Visual-mOtor integration is often defined
operationally as the ability to copy geometric shapes.
Beery (1982) suggested that the first nine figures in his
Dcvelopmental Test of Visual-Motor Integration should
be mastered before a child learns to write. The first nine
figures are a vertical line, a horizontal line, a circle, a
cross, a right-to-Idt diagonal, a left-to-right diagonal, an
X, a square, and a triangle. Lllldsey and Beck (1984) con-
sidered the ability to copy three shapes (circle, squal·e,
and triangle) as onc of the writing subskills. In the same
vein, Taylor (198'5) statec! that "if a pupil can manage to
copy the circle, cross and square, he is in a position to
learn to write most the letters with the exception of k v w
x z" (p 206). These authors agree that these basic shapes
should be mastered before a chilel starts to learn
handwriting.
The assumption that visual-IllOtor integration plays
an important role in handwriting gains support from two
empirical studies (Sovik, 1975; Tseng, 1991). Tscng
(1991) examined the relationship of a set of percepwal-
motor measures to legibility of handwriting in a group of
Chinese school-aged children. Results of regression anal-
yses indicated that visual-mot()l" integration as measured
Iw the Developnlental Tcst of Visual-Motor Integration
(Beery, 1989) was the [Jest predietm of Icgi!Jility of hand-
writing and accounted for 30% of variance on legibility
scores Sovik (1975) examined this relationship with both
American and Norwegian children and reponed a similar
finding
Rubin and Henderson (1982) compared handwriting
scores to scores on the Bender-Gestalt Test (KoppitZ,
1975), ;) measure of visual-motor integration, between
poor and good writers. The data indicated that poor writ-
ers were indeecl considerably worse than good writel-s;
however, the correlation between the children's Bender-
Gestalt tCSt scores and their handwriting scores was only
moderate (r = 49), showing that poor copying ability is
only l1loclerateJy associated with poor handwriting This
finding sugge.sts that handwriting is a complex skill and
that deficiencv in One aspect may not be sufficient ta
preelier the degree of poor handwriting
The Role of Fine ,li!otor and Motor Planning Skills
In delineating the sequence and stl-ucture of handwriting
competence, Taylor (1905) suggested that to hold and
manipulate the weiting tool efficiently presupposes fine
motor coordination to some degree. Levine et aL (1981),
in d studv of low prodUCtivity in school-agcel childl-en,
found that cllilclren with hanchvriting difficulty tended to
have problems in fine motor tasks. In their study, 72% of
children identified as having "developmental output fail-
ure" (low academic work output) were considered to
have clifficultv with fine motm tasks They postulated that
923
 uncoordinated finger movcmento; can lead to diminished
pencil CDntm!; this, they suggested, may result in writing
that is "illegible and/m laborious, hesitant, and slow"
(p. 20).
Rubin and Henderson (1982) examined the relation-
ship between handwriting performance and finc motor
skills as measured by five fine motor items of the Test of
Motor Impairment (TMI) (Stott, Moyes, & Henderson,
1972). The poor writero; were not significantly poorer at
fine motor skills than the control children, but a greater
variability of scores was noted among the poor writers. It
should be noted that each item of the TMI has a limited
range of scores, that is, either "below normal" or "nor-
ma!." As a result, the test may not be sensitive enough to
pick up differences.
According to Levine (1987), motor planning or praxis
is important for Skilled motor acts such as handwriting.
Levine cited Luria (1980) as describing two forms of the
problem of poor motor planning. One form of the prob-
lem is characterized by difficulty in formulating an ideo-
motor plan of what one intends to do. In the other case, it
is possible to formulate the plan, yet there is difficulty in
implementing it motorically because the central nervous
system mechanisms responsible for executing the plan
are disrupted. When either form of the problem exists,
handv,rriting difficulties ensue.
7.iviani et a1. (1990) addressed the role of motor
planning in relation to handwriting performance in chil-
dren with spina bifida. Motor planning, as measured by
the Motor AccuracyTest (Ayres, 1972), was not associated
with any legibility components or with writing speed.
Although the Motor Accuracy Test inclueles a component
of motor planning, it measures mainly eye-hand coordi-
nation. More recently, Tseng (1991) examined the contri-
butiono; of a variety of perceptual-motor measures to
handwriting in children from Taiwan through stepwise
regression analyses. She found that the Finger Position
Imitation Test (FiPIT) (Drucker, 1980), a test of motor
planning, was the best and only significant predictor of
legibility of poor writers. However, it only explained
10.3% of the variance in the legibility scores. It is likely
that handwriting is such a complex skill that many varia-
bles contribute to or hinder performance.
Summary and Implications for Treatment
The role of visual perception shows little relationship to
handwriting, whereas kinestheo;ia, visual-motor integra-
tion, and motor planning appear to be more closely relat-
ed to handwriting. The differ·ences in the outcomes of the
studies reviewcd here may be accounted for in pan by the
methodological inadequacies of many of the studies. Fur-
ther examination of perceptual-motor fauors and hand-
writing is warranted to provide cumulative data for vali-
dating the possible role of the underlying competencies
in handwriting.
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Most of the studies examining handwriting and fJer-
ceptual-motor components of performance have been
correlational Authors have assumed that if there is a
correlation between performance on the component and
handwriting, that problems in the component underlie
the handwriting problem, and that remediation of the
component will result in improvement in handwriting.
Although rcsearch has not shown these assumptions to
be incorrect, the correlational type of resear·ch does not
allow for these conclusions for scveral reasons. First, cor-
relation does not mean causation. Thus, if children who
have problems in visuospatial abilities also have problems
in handwriting, it does nor mean that the visuospatial
deficit causes or underlies the handwriting problem, be-
cause another variable might affect both visuospatial abili-
ty and handwriting. Second, remediation of the visuospa-
tial problems mayor may not result in improved
handwriting. Additional research is needed to directly
examine this assumption. In their examination of the
relationship between kinesthesia and writing, Laszlo,
Bairstow, and colleagues have studied the effects of kin-
esthetic training on writing, and have proVided models
for this type of needed research (e.g., Laszlo & I3airstow,
1983). Their studies provide preliminary support for the
assumption that improving kinesthetic perception will
result in improved writing.
At thiS time, much uf occupational therapists' work
with remediation of handwriting deficits in children is
based on clinical judgment and clinical reasoning. Al-
though practice in handwriting io; certainly one strategy, it
may be more effective when paired with (a) teaching
techniques that capitalize on the child's strengths, (b)
remediation procedures that develop foundation or per-
formance componcnts, or (c) compensation methods.
Cermak (1991) described several factms that can result in
different types of handwriting problems and discussed
intervention under three categories; demystification, by-
paso; strategies, and direct intervention Dernysfiji·caliun
involves explaining the problem to the child anel his or
her teachers. If the teachers understand the child's diffi-
culty, they will not attribute poor handwriting to laziness
and they will realize that when the child puts a lor of effort
into the graphomotor aspects of writing, his or her ability
to process the content of the inform;uion may be
compromised.
Bypass strategies involve circumventing the prob-
lem. One strategy involves altering expectations so that
demands are priol·itized. For example, if the primary pur-
pose of an assignment is content knowledge, then the
handwriting on that assignment may not be graded,
whereas another assignment may focus primarily on
handwriting. Environmental manipulations may also fa-
cilitate task performance. These might include using
graph paper to aid the chile! with spatial organization or
providing adaptcd writing tools. AnOlher example of a
bypass or compensatory strategy would be the use of a
October 1993, Volume 47. Number 10
 computer to minimize the handwriting demands. This
strategy may require teaching the child word processing
along with handwriting. Several articles have discussed
the use of word processors for improving children's writ-
ing (e.g., Glazer & Curry, 1988; Hunter,jal-cline, Rilstone,
& Weisgerber, 1990; Majsterek, 1990; Outhred, 1989).
Many of the ergonomic principles, such as adapting the
environment, would be categorized under this type of
intervention.
The third and final approach is direct intervention.
The goal of treatment is for the child's writing to become
automatic and fluid so that the child does not have to
think about letter formation and can produce an ade-
quate volume of work in an expected period of time
without undue fatigue. Remediation of handwriting
should always be done in conjunction with the child's
teacher so thar a consistent approach to teaching hand-
writing is used. Practice with letter formation is certainlv a
necessary component of remediation. In addition, the
child's motor skills and sensory processing abilities that
contribute to and are considered to underlie good hand-
writing are important to consider. For example, some
childl·en with poor handwriting have inadequate somato-
sensory perception, which may be manifested in finger
identification and tests of kinesthetic perception. The
child who does not adequately process somatosensorv
information mal' overrely on the visual svstern and posi-
tion his or her head close to the paper to Visually monitor
the hands. To tl)' to increase somatosensory feedback,
the chi ld may develop poor pencil grasp, characterized by
stabilization of the distal joints. Although this may be
adequate for small amounts of writing, it produces fatigue
when the writing demands are great (Levine, 1985). Re-
cemly, several studies have discussed the importance ofa
kinesthetic approach in the remediation of handwriting
problems in children. Laszlo ct al. (Laszlo & Bairstow,
1985; Laszlo, Bairsrow, & Bartrip, 1988) described specific
training of kinesthetic perception. Benbow (1990; in
[xess) also has supported the use of a kinesthetic ap-
proach fur teaching handwriting. She has emphasized
that kinesthctic processing is even mOl'e imponanr for
cursive than for manuscript writing.
Handwritlllg is a complex task, and various factors
are related to skilled handwriting. Various procedures
have been suggescecl by educators and therapists to facili-
tate handwriting. These procedures need to be mme fully
examined to determine whether specific approaches arc
more effective for remecliating cenain types of handwrit-
ing errors ....
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Oerober 1993, Volume 47, Nlimber 10