How effective are school based practice occupational therapists in fostering in-hand manipulation skills to improve handwriting in children ages 2-8?

Table 1 Author:Allison Hammer

Author, Year

/ Study Objectives / Study Design/ Participants / Level of Evidence / Sample Size / Interventions & Outcome Measures / Summary of Results (Conclusion & Implications) / Study Limitations
Point, K.,
Wallen, M.,
Bundy, A., &
Case-Smith,
J. (2008). / Examine
construct validity, test-retest reliability, and interrater reliability of TIHM, and propose adaptations so that the test would be valid, reliable, and clinically useful. / Pre-Experimental Design with pre-post one group design.
Typically developing Kindergarten and First Grade students between the ages of 5.5 and 6.5 / III / 45 / Child was asked to complete the TIHM with dominant hand, and was scored at time of administration. Was videotaped for evaluating interrater reliability.
Child was tested again 2 wks later, to examine test-retest reliability.
27 videotapes were selected and reviewed by 3 OT’s and 2 OTS, resulting in 100 paired data sets for interrater reliability analysis.
Rash analysis using Windteps program provided information about the variance that exists in the tool, and the rating scale structure. Examined construct validity and aspects of reliability. / Limited evidence for validity of the original TIHM because of large number of items that did not conform to the expectations of the Rasch model (43%).
The test was revised. Quality ratings were removed from test, translation with two and three pegs were converted into practice tasks. Collapsing rating scale structure increased the test’s sensitivity with this age group.
Interrater reliability of the revised version was very high. Test-retest reliability was inadequate. Lack of stability shows that it cannot be used as an outcome measure with this age group. / Small sample size, limited generalizability due to inclusion criteria of typically developing children to other age groups or children with suspected dysfunction.
Humphry, R.,
Jewell, K., &
Rosenberger,
R. (1995). / Examine the age-related increase of in-hand manipulation, the consistency of using a manipulation strategy and the relationship between the frequency of in-hand manipulation and activities that often require use of intrinsic hand control. / A non-probability design with a convenience sample was used.
184 children between the ages of 2 and 7 were recruited from local after school programs and day care centers. 6 and 7 year olds were included to increase the probability of observation of consistent, skilled performance in the activities. Subjects were primarily white, from middle socioeconomic homes, and over half were boys.
Selection criteria included the following: signed parental consent, age equivalent performance on Developmental Test of Visual Motor Integration no lower than 12 month difference between their chronological age. / III / 184 / The second author designed and standardized materials and instructions for eight child-appropriate activities that permitted observations of in-hand manipulation skills and five activities related to performance areas.
The child’s performance was then observed during selected activities that could demonstrate three forms of in-hand manipulation. Observation and activity analysis were used and stability of measures in the research protocol was examined. A total score of in-hand manipulation was obtained by summing the three subscale scores. / The frequency of two types of in-hand manipulation increases with age and illustrated the uneven nature of development of different types if in-hand manipulation.
Findings of the study suggest the need to consider in-hand manipulation development in light of the dynamical systems model. The findings raise questions as to whether maturity of in-hand manipulation may be a factor limiting performance in the everyday activities of typically developing children. / Generalization of scores from this study is limited because the sample of children was homogeneous and does not reflect the ethic or socioeconomic diversity that a random sample would obtain.
The study was conducted on typically developing children; so application to children with developmental disabilities who may follow different patterns of development were not included.
Validity of activities selected in this research protocol is also a limitation.
Case-Smith,
Jane. (2002). / Examine the effectiveness of school-based occupational therapy services on children’s handwriting. / A quasi-experimental design was used with no random assignment, a comparison and experimental group, post test and follow up interviews with the therapist.
Occupational Therapist recruited students from central Ohio and southern Illinois who were identified by their teachers as having poor handwriting. Students were among the second, third, and forth grade. The experimental group received OT services, while the comparison group did not. / III / 38 / Three subtest of the Developmental Test of Visual Perception were used to measure position in space, copying, and figure ground perception.
The Bruiniks-Oseretsky Test of Motor Proficiency looked at the motor functioning of children, and two of those subtests were used to test fine motor skills.
The translation and rotation components of in-hand manipulation were measured with the 9-hole peg test.
The Evaluation Tool of Children’s Handwriting looked at speed and legibility. All of the subtests were administered.
The OT and teachers working with student in the intervention group were given two sections of the School Function Assessment to complete in order to evaluate participation in school activities.
Evaluation occurred during the regular school day. Twelve OT’s carried out the interventions for a seven-month time period. Follow up interviews were also conducted with OT’s and teachers. The Statistical Package for the Social Sciences version 10, the standard deviation and means were collected and examined for all tests.
Throughout the time of the student 16 sessions were provided, for about 30 minutes, with a total of 528 minutes of OT services. Handwriting activities or practice took place in 77% of the sessions. / Significant changes were seen in the areas of in-hand manipulation, visual-motor control, and position in space perception.
The intervention group improved more than the comparison group with in-hand manipulation, visual-motor control, and legibility of letters.
The SFA criterion scores on written work increased by twelve points and showed that students had better functioning with school activities involving manipulating materials and written communication. / Generalizability was limited due to the use of only one geographical region and sample size. A descriptive outcome design limited interpretation of the reasoning behind the effectiveness of the intervention. The two groups were very uneven in size and information about the participant’s educational program was not collected.
Case-Smith, J.,
Heaphy, T.,
Marr, D.,
Galvin, B.,
Koch, V.,
Ellis, M., &
Perez, I.
(1998). / Evaluate fine motor and related functional outcomes in preschool children that are receiving occupational therapy services. / Experimental-type research design was used with no random assignment, a comparison and experimental group, post test and follow up interviews with the therapists and parent.
Participants were attending preschool and 3 ½ to 6 years of age. 44 children participated, 44 with fine motor delays who received occupational therapy services and 20 without delays who did not receive services. / II / 64 / A comprehensive battery of 11 assessments was administered to participants at the beginning and end of the school year. They were tested in their homes, and parent and teacher interviews occurred within 2 weeks of testing the child.
The five small pegs and peg board from the Nine-Hole Peg Test was used to assess the in-hand manipulation tasks of rotation and translation.
The MAC test of the SIPT is a paper and pencil task that measures eye-hand coordination. The Manual Form Perception (MFP) test of the Southern California Sensory Integration Test was used to measure stereognosis.
Two subtests of the developmental Test of Visual Perception (DTVP), the Position in Space test and Finger Ground test, were used to measure visual perception.
The child’s parent completed the Sensory Profile, and the PEDI and Functional Scale for Self-Care, Mobility, and Social Function were both administered.
The PDMS-FM was administered to measure overall fine motor performance, two subtests of the DTVP looked at visuomotor skills, the Draw-a-Person test measured integration of those visuomotor skills, and the Functional Skills test measured their independence and quality of performance.
Direct intervention was provided each week and recorded by occupational therapists. Information was entered into an SPSS program and the ANOVAs were used to analyze the difference between scores on the pretest and posttest. / Those without fine motor delays made significant improvements in in-hand manipulation, MFP, visuoperception, draw-a-person, visuomotor skills, functional skills, and PEDI self-care function. Those with fine motor delays made significant improvements in all but two of the measures, the Sensory Profile and Self-Esteem.
Participants who received services improved more than those not receiving services on five tests: in-hand manipulation, MAC, functional skills, draw-a-person, and PDMS-FM.
Students with fine motor delays who received regular occupational therapy services from the beginning to the end of the school year improved significantly, more than those typically developing, in the fine motor parameters measured. / The results suggested that greater application was to the geographical areas of Ohio and New York since the majority of participants were from there. The form completed by the practitioners did not undergo sufficient testing for validity, so it is questionable if the most relevant aspect of interventions were measured. The functional skills and self-esteem measures had limited evidence of reliability and validity, and should need further test development.
Pont, K.,
Wallen, M.,
& Buncy, A.
(2009). / Existing classification systems of in-hand manipulation were closely examined. An adaptation of Exner’s classification system was proposed, containing more discrete categories of in-hand manipulation movements. / Reviewed the literature and proposed an adaptation for a new classification system for in-hand manipulation. / V / N/A / N/A / The authors increased the consistency between Elliott and Connolly’s and Exner’s classifications to develop a uniform assessment measure to look at IHM. / Level V evidence. There needs to be a reliable, consistent, and valid assessment to explore the relationship between IHM and fine motor skills, handwriting, and self-care.
Pehoski, C.,
Henderson,
A., & Tickle-
Degnen, L.
(1997). / This study looked at the development of in-hand manipulation skills in young children and describes the developmental trends that can be observed when a small object is moved in and out of the palm. / A non-probability design was used with a convenience sample, recruited from after school programs or nursery schools in the middle and upper class communities in Boston.
All participants were right handed, 154 children between the ages of 3-7 and 13 adults between 28-39 years old. / III / 154 / A pegboard and small pegboard were used for this study. Each participant was seen individually and videotaped. The following tasks were given to the participants: Finger-to-Palm Translation With Stabilization (storing the peg in palm) and Palm-to-Finger Translation With Stabilization (retrieving the peg). Four methods were evaluated: gravity assisted, rake, no translation, and surface or other hand.
Two-way analysis of variance (ANOVAs) was done to look at the difference between the performance of boys and girls, and groups. Independent t test were then done. / There was a gradual increase with age in the number of pegs successfully handled in these two trials. Moving the peg from fingers to palm for storage was a simple task for most, and they were able to pick up and hold 2-5 pegs in their hand without dropping them. Girls used the gravity-assisted method more often than boys.
Children 3-7 had difficulty managing four and five pegs, and dropping pegs was more common with the Palm-to-Finger Translation With Stabilization task. Many children maintained their hand in a pronated position for both the pick up and storage of pegs. / The participants were chosen using a convenience sample, and they were all from the same area and socioeconomic status. The participants were all right handed as well.
Exner,
Charlotte.
(1993). / This was a content validity study conducted in order to obtain information necessary for improving the In-hand Manipulation Test. It looks at the IMT’s content, structure, rating system, and appropriateness for measuring the in-hand manipulation skills of a child. / Factorial design with a convenience sample, and random selection of groups.
OT’s from the Baltimore-Washington area participated in this study. They had pediatric experience for at least one year, including experience in assessment of children’s fine motor skills. Mailing labels were obtained from the American Occupational Therapy Association. Therapists were then divided into two groups depending on their pediatric experience. / V / 24 / The IMT was administered to 16 children and videotaped. Occupational therapist viewed the tapes and rated them. Written and oral feedback was received, and a survey was completed in order to collect information about the test. / Some concerns were raised about using the assessment with children under the age of 2. Twelve of the raters stated that the medium sized objects and 1 inch cubes presented difficulties for many children, and suggested that several different sizes be used so that the test can be modified according to a child’s hand size. The items related to scoring has a mean score of agree, and the majority of raters found the test appealing. 8 items were found difficult to score, and 4 were considered easy to score.16 of the 24 raters believed that they would not have difficulties administering this test. / OT’s were recruited from only one area. The answers from surveys could be subjective.
Breslin, D., &
Exner, C.
(1999). / This study was designed as one in a series of studies examining the validity of the IMT. This particular study assessed the ability of test to discriminate between samples of children with and without known fine motor problems. / This quasi-experimental design had no random assignment of participants and was a longitudinal time series.
The children without fine motor problems were between 3-9 years old who previously participated in the 1994 test-retest reliability study of the IMT. They were enrolled in either day-care programs or before school and after school programs in the Baltimore metropolitan area.
The children with spastic diplegia were recruited from the Kennedy Krieger Institute in Baltimore as those with fine motor problems who were receiving occupational therapy services. They were between the ages of 3-8 and each one had a combined IQ of 70 or above. / II / 55 children without fine motor problems and 24 children with spastic diplegia. / The IMT was administered and each item was scored on a 4 point rating scale. Children with spastic diplegia were given the IMT at the Kentucky Krieger Institute, and their scores were compared with the scores of the children without fine motor problems.
The statistical computer program SPSS for Windows, Release 6.0 was used to analyze the data, a t test was calculated for the man IMT total score, which determined whether significant differences in IMT performance existed between the group without fine motor problems and the group with spastic diplegia. / The mean total for the group without fine motor problems was 126.13 and for the spastic diplegia group, it was 87.17.
For each analysis, the overall percentages of all children correctly classified were 79.49%. The misclassified children were with children without fine motor problems.
The overall percentage of children correctly classified with six significant variables was 96.20%. This shows that the total scores of the IMT accurately discriminate between children without identified fine motor problems and those with mild to moderate fine motor problems as a result of spastic diplegia. / The increased percentage of misclassified children may have been due to the small sample size, which limits confidence of generalization of the results to other children. The disparity in the size and hand performance distribution of the two groups of children limits confidence in the results.
Cornhill, H.,
Case-Smith,
J. (1996). / The purpose of this study was to investigate the relationship between specific performance components, including in-hand manipulation, and handwriting skill. / A non-probability design with a convenience sample was used for this study.
Typically developing first grade children from one county of central Ohio were used. None of them had a learning disability, developmental delay, or sensory impairment. Their teacher judged them as a good or poor handwriter, and they then completed the MHT as an assessment of legibility to clarify their handwriting ability. / III / 48 / Participants were tested individually in 20-25 minute sessions. The following tests were administered: Motor Accuracy Test, the Developmental Test of Visual Motor Integration, the rotation and translation tasks of in-hand manipulation, and the Minnesota Handwriting Test.