Seminar 2 –
Assessment

Anna Barnett:
Oxford Brookes University, England

Handwriting: Its assessment and role in the diagnosis of Developmental Coordination Disorder

Handwriting remains an important skill
Students must be able to produce fast and legible handwriting in order to keep up with school work and achieve their full potential in examinations, particularly in the secondary school. Poor handwriting can lead to academic underachievement and low self-esteem.

For some children, technology can help to produce work neatly and quickly, for example by touch typing. However, many recognise that handwriting remains an important skill to learn. There are times when handwriting is the only option (e.g. writing cheques, filling in forms). Also, the provision of alternatives can be difficult and costly. Children with DCD may have difficulty in learning keyboarding skills and the necessary resources for hardware, software, training and technical support are sometimes difficult to secure.

Handwriting difficulties are common in DCD
Handwriting difficulties are commonly reported in children with DCD. They are frequently mentioned when children are referred for occupational therapy (Malloy-Miller et al., 1995) or physiotherapy (Peters et al., 2004); they are listed at all ages as a problem affecting Activities of Daily Living (ADL; Geuze, 2004) and handwriting problems continue to be evident in adulthood (Cousins & Smyth, 2003).

As well as professionals, parents and the children themselves are also concerned about lack of skill in this area and often choose to work on handwriting in therapy sessions (Mandich et al., 2003; Miller et al., 2001; Dunford, 2004).

Handwriting and Criterion A
Difficulties in handwriting for children with DCD have been formally recognised in Criterion A of the DSM-IV:

‘Performance in daily activities that require motor coordination is substantially below that expected given the person’s CA and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things, “clumsiness”, poor performance in sports, or poor handwriting.’

This general description of motor difficulties has been criticized for its lack of specificity. Some have questioned whether a set of ‘core deficits/symptoms’ can be identified to aid diagnosis, as has been achieved in other developmental disorders (e.g. autism, ADHD). The diagnosis of DCD has not yet progressed to this level of sophistication. If it did, difficulties with handwriting would undoubtedly be included in a list of ‘core’ symptoms.
One potential problem is that handwriting difficulties are not restricted to children with DCD. It is well documented that handwriting difficulties are common in children with dyslexia, ADHD, Asperger’s syndrome and Specific Language Impairment. In addition, when teachers in regular classrooms are asked to estimate the proportion of children with handwriting difficulties in their class, this is typically about 12%, quite a high proportion.

It is not known how many of these children have other difficulties and how many have only handwriting difficulties. This needs further investigation to better understand the significance of handwriting difficulties in children with DCD.

Handwriting and Criterion B
‘The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living’

For children of school age, handwriting is an activity of daily living. It is an important part of learning and assessment across the school curriculum and much time is spent handwriting during the school day. Knowledge and skills are assessed through the medium of handwriting and it continues to be a needed skill in adulthood as at university many examinations are still handwritten. It has been well established that poor fluency in writing is related to reduced quantity and quality of written content (Connelly et al., 2002; 2005) and it has long been recognised that poor handwriting can lead to academic underachievement (Briggs, 1970; McGinnis, 1992; Simner et al., 1996).

Assessment of Handwriting Skill
Handwriting may be assessed for a variety of reasons including identification, description, quantification, monitoring and intervention. For any of these applications it is important to consider measurement issues for this particular skill. It is usual to consider two different aspects in the assessment of handwriting (1) the final product (in terms of quality and speed of production) and (2) the writing process (how writing evolves, posture of the writer). It is also important to consider the skill in a wider context in terms of how the skill has been taught and what other literacy and language skills the child has.

Handwriting is included in some observation checklists (such as the DCDQ and Movement ABC Checklist). Here the parent or teacher judges the child’s level of performance based on their observations of the child in a natural setting. Handwriting is just one of many other skills assessed and a global judgement is usually made.

Handwriting is not assessed in any of the major motor proficiency test batteries (Movement ABC, BOTMP, MAND, TGMP). It is quite right that it is not included in these batteries as it is very different to the other motor skills assessed. Handwriting is not purely a ‘motor’ skill, it involves complex cognitive and perceptual skills and developing the skill is dependent on being taught. It is not a skill that evolves naturally. There is enormous variation in teaching of this skill, in terms of time spent teaching, methods employed etc. There is variation between countries, schools and even classes within a school. It is therefore hard to envisage a test of handwriting skill that would be suitable across different settings.

Some standardized handwriting tests have been used in research on DCD, such as the BHK from the Netherlands and the ETCH from the US. Both of these provide very detailed descriptions of handwriting performance. There are currently no suitable handwriting tests with UK norms available.

Development of a test of handwriting speed in the UK
A project is currently underway to produce an instrument with UK norms suitable for quantifying handwriting performance and identifying children with handwriting difficulties. This would be useful for children with DCD and other children with handwriting difficulties. The major focus of this project is on handwriting speed.
When designing a test of handwriting speed there are important decisions to be made regarding the type of writing task (copying or ‘free’ writing), the instructions used (relative emphasis on speed or legibility), the overall length of the task and how to score performance (letters or words per minute, whether or not to include illegible words). There are many different components to handwriting. Ideas have to be generated and selected and sentences have to be planned before the mechanical aspects of writing are executed. In this project we are interested in the motor component of the task and aim to isolate this from other aspects of writing while retaining an ecologically valid task.

I outlined a range of writing tasks that we have been using in an attempt to tease out different components of the writing task. This has included a symbol writing task, writing out the alphabet, a copying task and a ‘free’ writing task, all suitable for children aged 9 to 16 years. My focus was primarily on the ‘free’ writing task.

The ‘free’ writing task is considered to be the most ecologically valid and favoured by classroom teachers. In order that writing output is not restricted by not knowing what to write about, a topic was chosen that was considered to easily generate ideas. Some pilot work suggested for example, that students more easily produced text on the topic of ‘my life’ than on ‘my favourite person’. We used a 15-minute duration task, divided into 3-minute periods so that the production over time could be examined. Interestingly, while we found significant gender effects (in favour of girls) in the ‘free’ writing task, these were less obvious and not significant in our other, shorter copying and symbol writing tasks.

We want to develop a test that is suitable for use in a group setting, so that a whole class of students could be tested at the same time. However we are also aware that there are times when children (particularly those with special needs) will undergo detailed individual assessment by a teacher or other professional (e.g. an educational psychologist or occupational therapist). We were concerned that results on the test may be different when performed in a group and an individual setting. However when we formally examined this we found no statistically significant differences in the amount of writing produced in an individual compared to group setting.

We have managed to examine some aspects of reliability on our test of handwriting speed, with positive results for inter-tester and test-retest reliability.

The collection of UK norms is now underway on our test of handwriting speed. This will allow for the identification of those with handwriting difficulties and allow for handwriting to be quantified to help with monitoring performance over time. It may also help in the application of special access arrangement such as extra time in examinations, where appropriate.

The questions discussed following this presentation were:

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